A nurse is providing discharge teaching to the family of a client who has Alzheimer's disease. Which of the following instructions should the nurse include in the teaching?
Keep a monthly calendar in the client's kitchen.
Provide distraction by keeping the television on.
Install a nightlight in the client's bedroom
Place a deadbolt lock on the client's bedroom door.
The Correct Answer is C
A. Keep a monthly calendar in the client's kitchen: A calendar showing a full month may be difficult for a client with Alzheimer's disease to process due to impaired memory and orientation. Simpler visual aids or daily reminders are more effective in supporting cognitive function.
B. Provide distraction by keeping the television on: Leaving the television on continuously can overstimulate the client and contribute to confusion or agitation. Clients with Alzheimer's often benefit more from calm, structured environments than from constant auditory input.
C. Install a nightlight in the client's bedroom: Installing a nightlight helps maintain orientation and reduce nighttime confusion. It also lowers the risk of falls by making it easier for the client to navigate their environment if they wake during the night.
D. Place a deadbolt lock on the client's bedroom door: Locking the client in their bedroom poses serious safety concerns, especially in emergencies like a fire. It may also increase anxiety or fear. Safer wandering prevention measures include door alarms or monitoring systems.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Crackles in the lungs: Pulmonary edema causes fluid accumulation in the alveoli, leading to crackles or rales heard during auscultation of the lungs.
B. Jugular vein distension: Increased pressure in the pulmonary circulation can lead to right-sided heart strain, resulting in visible jugular venous distension.
C. Persistent, dry cough: Cough in pulmonary edema is typically productive, often associated with pink, frothy sputum due to fluid leakage into the alveoli.
D. Frothy, blood-tinged sputum: A hallmark sign of pulmonary edema, this occurs as fluid mixed with blood leaks into the alveoli and airways due to high pulmonary capillary pressure.
E. Bradycardia: Pulmonary edema is typically associated with tachycardia as a compensatory response to hypoxia and impaired cardiac output, not bradycardia.
Correct Answer is C
Explanation
A. “Avoid high-fiber foods while taking this medication.”: Fentanyl can cause constipation, so a diet high in fiber is actually recommended to promote bowel regularity. Avoiding fiber would worsen one of the drug’s common side effects.
B. “Remove the patch for 8 hours every day to reduce the risk of tolerance.": Fentanyl patches are designed for continuous, 72-hour use. Removing the patch disrupts pain control and may lead to withdrawal symptoms or inadequate analgesia.
C. “Avoid hot tubs while wearing the patch.”: Heat exposure, including hot tubs or heating pads, can increase fentanyl absorption, potentially leading to overdose. Clients should be advised to avoid external heat sources near the patch.
D. “Apply the patch to your forearm.”: The patch should be applied to a flat, non-irritated area of the upper torso or upper arm. The forearm is not typically recommended due to its mobility and potential for detachment or reduced absorption.
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