A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease.
The client becomes agitated and combative when the nurse approaches him.
Which of the following actions should the nurse plan to take?

Calmly ask the client if he would like to listen to some music.

Turn the water on and ask the client to test the temperature.

Firmly tell the client that good hygiene is important.

Obtain assistance to place mitten restraints on the client.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

It is essential for the nurse to employ non-pharmacological interventions to manage behavioral issues in clients with Alzheimer's disease. Offering to play music is a suitable approach to distract and soothe the agitated client. Music can have a calming effect and may help reduce anxiety and agitation in clients with dementia. It is a safe and non-invasive intervention that respects the client's autonomy and preferences.

Choice B rationale:

Turning the water on and asking the client to test the temperature (choice B) may not be an appropriate initial response. This action may increase the client's agitation as it involves immediate physical contact and may not address the underlying issue of the client's distress.

Choice C rationale:

Firmly telling the client that good hygiene is important (choice C) is not a recommended approach. Using a firm tone or being authoritative can escalate the client's agitation and may not effectively address the behavioral issue. It's important to use a calm and respectful approach when caring for clients with Alzheimer's disease.

Choice D rationale:

Obtaining assistance to place mitten restraints on the client (choice D) should not be the first choice. Restraints should only be used as a last resort when other methods have failed, and they should be used in accordance with institutional policies and guidelines. Restraints can have adverse physical and psychological effects and should be avoided whenever possible.

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Correct Answer is B

Explanation

Correct answer is: B. 16 lb.

Choice A rationale: 32 lb. is too much weight gain for a client whose prepregnancy BMI was 30.5. According to the Institute of Medicine (IOM) guidelines, obese women (BMI greater than or equal to 30) should only gain 11 to 20 lb.during pregnancy 1 2.Excessive weight gain can increase the risk of gestational diabetes, hypertension, cesarean delivery, and postpartum weight retention 1.

Choice B rationale: 16 lb. is an acceptable weight gain for a client whose prepregnancy BMI was 30.5. This is within the recommended range of 11 to 20 lb.for obese women (BMI greater than or equal to 30) by the IOM guidelines 1 2.Adequate weight gain can help ensure optimal fetal growth and development, as well as maternal health 1.

Choice C rationale: 24 lb. is too much weight gain for a client whose prepregnancy BMI was 30.5. This exceeds the recommended range of 11 to 20 lb.for obese women (BMI greater than or equal to 30) by the IOM guidelines 1 2.Excessive weight gain can increase the risk of gestational diabetes, hypertension, cesarean delivery, and postpartum weight retention 1.

A. Hypothermia. B. Muscle weakness. C. Somnolence. D. Hallucinations.

Correct Answer is D

Explanation

The correct answer is d. Hallucinations.

Choice A reason: Hypothermia is not typically associated with MDMA use. Instead, MDMA can cause hyperthermia due to its stimulant effects.

Choice B reason: Muscle weakness is not a common effect of MDMA. The drug is more likely to cause increased energy and endurance.

Choice C reason: Somnolence, or a strong desire for sleep, is unlikely with MDMA use as it is a stimulant and tends to increase alertness.

Choice D reason: Hallucinations are a known effect of MDMA use, where users may experience distortions in perception. Methylenedioxy-methamphetamine (MDMA) is known to cause perceptual changes, including hallucinations.

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A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease.The client becomes agitated and combative when the nurse approaches him.Which of the following actions should the nurse plan to take?

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A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease.
The client becomes agitated and combative when the nurse approaches him.
Which of the following actions should the nurse plan to take?