A nurse is planning care for an older adult client who has moderate Alzheimer's disease. Which of the following interventions should the nurse implement in the client's plan of care?
Maintain scheduled daily routines for the client.
Use long sentences when speaking with the client.
Provide the client with increased environmental stimuli.
Ensure all siderails are up on the client's bed when they are sleeping.
The Correct Answer is A
Rationale:
A. Maintain scheduled daily routines for the client: A consistent daily routine helps reduce confusion and anxiety in clients with Alzheimer’s disease by providing structure and familiarity. Predictability supports cognitive function and enhances a sense of security.
B. Use long sentences when speaking with the client: Long or complex sentences can overwhelm clients with moderate Alzheimer’s disease. Simple, short sentences with clear instructions are more effective for promoting understanding and cooperation.
C. Provide the client with increased environmental stimuli: Too much environmental stimulation can lead to agitation, confusion, or sensory overload in individuals with Alzheimer’s disease. A calm, quiet environment is more appropriate to help maintain focus and comfort.
D. Ensure all siderails are up on the client's bed when they are sleeping: Raising all side rails can pose a safety risk by increasing the likelihood of injury from attempts to climb over them. Alternatives like using a low bed and ensuring supervision are safer and more appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Dependent edema: This occurs due to fluid buildup in the peripheral tissues, which is typically caused by right-sided heart failure. It reflects systemic venous congestion rather than pulmonary issues associated with left-sided failure.
B. Jugular distention: Jugular venous distention is a sign of increased central venous pressure and is more often associated with right-sided heart failure, not the pulmonary congestion seen in left-sided failure.
C. Weight gain: Weight gain from fluid retention is more indicative of right-sided heart failure, which causes systemic congestion; it is not a primary manifestation of left-sided heart failure.
D. Frothy sputum: Frothy, often pink-tinged sputum results from pulmonary edema caused by left-sided heart failure. Blood backs up into the lungs due to poor left ventricular function, leading to fluid leakage into the alveoli.
Correct Answer is B
Explanation
Rationale:
A. Use a 3 mL syringe to flush the PICC following infusions: A syringe smaller than 10 mL creates excessive pressure, which can damage the catheter. A 10 mL syringe or larger should always be used to flush a PICC to maintain catheter integrity.
B. Assess the PICC infusion system systematically: Systematic assessment of the PICC line, including the site, tubing, and connections, is essential for detecting complications such as infiltration, infection, or occlusion. This promotes safe and effective use of the catheter.
C. Change the needleless connector device on the IV tubing after each infusion: The needleless connector device does not need to be changed after each infusion. It is typically changed every 7 days or if contamination, leakage, or other issues are noted.
D. Provide daily dressing changes to the PICC insertion site: PICC dressings should be changed every 7 days if using a transparent dressing, or sooner if the dressing becomes damp, loose, or visibly soiled. Daily dressing changes increase infection risk unnecessarily.
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