A nurse is contributing to the plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Encourage socialization as a distractor when the client becomes agitated.

Limit instructions to two steps at a time.

Vary the staff providing care for the client

Encourage independence in ADLs.

Answer and Explanation

The Correct Answer is B

A. "Encourage socialization as a distractor when the client becomes agitated.": Socialization might exacerbate agitation; calm environments and redirection are better strategies.
B. "Limit instructions to two steps at a time.": Simplified instructions accommodate the cognitive limitations of Alzheimer’s clients, reducing confusion and frustration.
C. "Vary the staff providing care for the client.": Consistent caregivers are essential for maintaining familiarity and reducing anxiety in clients with Alzheimer's disease.
D. "Encourage independence in ADLs.": Independence should only be encouraged as much as the client can manage safely; overemphasis might lead to frustration or harm.

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Correct Answer is A

Explanation

A. Empty the pouch when it is 1/3 to 1/2 full: This prevents the weight of the pouch from causing leaks or pulling on the stoma.
B. Use a standard enema set to irrigate the colostomy: This is incorrect as a standard enema set is not typically used. Colostomy irrigation requires specific equipment and is not performed routinely.
C. Cleanse the skin surrounding the stoma with moisturizing soap: Moisturizing soap can leave a residue that interferes with adhesive barriers. Mild, non-moisturizing soap or just water should be used.
D. Cut the opening in the skin barrier 1/4 inch larger than the stoma: The opening should fit closely to the stoma to protect the surrounding skin from irritation and leakage.

A. The client should wear a mask during transport. B. The nurse should wear a mask during transport. C. The nurse should wear a gown during transport. D. The client should wear a gown during transport.

Correct Answer is A

Explanation

A. The client should wear a mask during transport. In droplet precautions, the primary goal is to prevent the spread of respiratory secretions. The client wearing a mask during transport helps contain droplets and protect others.
B. The nurse should wear a mask during transport: While the nurse can wear a mask when in close contact with the client, it is more effective for the client to wear a mask to contain respiratory droplets.
C. The nurse should wear a gown during transport: Gowns are not required for droplet precautions unless there is a risk of contact with bodily fluids.
D. The client should wear a gown during transport: Gowns are unnecessary for droplet precautions unless the client’s clothing is contaminated.

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A nurse is contributing to the plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

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