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 A
Explanation
Rationale:
A. Respiratory alkalosis: The pH is elevated at 7.48, and the PaCO₂ is decreased at 30 mm Hg, indicating a loss of carbon dioxide due to hyperventilation. The HCO₃ is within normal range, confirming the imbalance is respiratory in origin. This pattern reflects respiratory alkalosis, which is commonly caused by anxiety-induced hyperventilation.
B. Respiratory acidosis: Respiratory acidosis is characterized by low pH and elevated PaCO₂. In this case, the pH is high and PaCO₂ is low, which is the opposite pattern of respiratory acidosis.
C. Metabolic alkalosis: Metabolic alkalosis involves an elevated pH with an increased HCO₃. While this client’s pH is elevated, their HCO₃ is normal, making a metabolic cause unlikely.
D. Metabolic acidosis: Metabolic acidosis presents with a decreased pH and decreased HCO₃. The client’s pH is high and HCO₃ is within the normal range, ruling out this imbalance.
Correct Answer is B
Explanation
Rationale:
A. Instruct the client to lift no more than 6.8 kg (15 lb) when at home: While it is important to avoid heavy lifting after a lumbar laminectomy, specific weight limits should be prescribed by the provider or physical therapist. Also, this instruction is more appropriate for discharge teaching, not immediate postoperative care.
B. Turn the client by log rolling with a turning sheet: Log rolling maintains spinal alignment and minimizes twisting of the spine, which is critical after spinal surgery. It prevents stress on the operative site and reduces the risk of complications such as spinal cord or nerve injury.
C. Inform the client to shower on the second postoperative day: Showering is usually permitted after surgical wounds have started to seal, but the exact timing depends on the surgeon's orders and the condition of the incision. Automatic showering on day two may not be safe for all clients.
D. Remove sterile adhesive strips before discharge: Sterile adhesive strips (such as Steri-Strips) are typically left in place until they fall off naturally or are removed by a healthcare provider at a follow-up visit. Removing them prematurely can increase infection risk or disrupt healing.
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