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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?

A.

Maintain scheduled daily routines for the client.

B.

Use long sentences when speaking with the client.

C.

Provide the client with increased environmental stimuli.

D.

Ensure all siderails are up on the client's bed when they are sleeping.

Answer and Explanation

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.


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Related Questions

Correct Answer is D

Explanation

Rationale:
A. N95 respirator: N95 respirators are required for airborne precautions, such as with tuberculosis, measles, or varicella. Bacterial meningitis, caused by organisms like Neisseria meningitidis, requires droplet precautions, which do not necessitate an N95 mask.

B. Goggles: Goggles are used for protection against splashes or sprays of bodily fluids, particularly in procedures that may cause aerosolization. While helpful in certain situations, goggles are not required as part of standard droplet precautions for meningitis.

C. Disposable gown: Gowns are worn during contact precautions or when there is a risk of contamination from bodily fluids. They are not routinely required for droplet precautions unless the nurse anticipates contact with large amounts of secretions.

D. Surgical mask: A surgical mask is the appropriate PPE for droplet precautions, which are necessary for clients with bacterial meningitis. The mask prevents the spread of infectious respiratory droplets that can travel up to 3 feet during coughing or sneezing.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Rationale:

  • Place on a Low-protein diet: A low-protein diet is often prescribed in clients with hepatic encephalopathy to reduce ammonia production from protein metabolism. With an ammonia level of 150 mcg/dL and signs of chronic liver disease, this is appropriate.
  • Daily abdominal girth measurements: This client has a distended abdomen with dullness to percussion, suggesting ascites. Measuring abdominal girth daily helps monitor fluid accumulation and response to diuretics or fluid restriction.
  • Daily weights: Weight tracking is essential in clients with ascites or fluid imbalance, common in cirrhosis. It provides a sensitive indicator of fluid retention or loss over time.
  • Liver biopsy: With thrombocytopenia (platelets 120,000/mm³), active GI bleeding, and coagulopathy likely due to cirrhosis, liver biopsy poses a high bleeding risk and is not appropriate in this unstable condition.
  • Administer lactulose: Lactulose is a first-line treatment for hepatic encephalopathy. It works by trapping ammonia in the colon and promoting its excretion. This is essential given the client's elevated ammonia level and risk for mental status changes.
  • Liver ultrasound: A liver ultrasound is a non-invasive imaging tool to evaluate liver size, structure, and presence of masses or ascites. It is safe and appropriate in this client's condition and can guide further management.

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