A nurse is providing teaching for the family of a client who has Alzheimer's disease. Which of the following statements should the nurse include?

"Display a monthly calendar in the client's room."

"Provide plenty of stimulation in the client's room."

"Keep the client's room dark at night to promote sleep."

"Provide the client with structured activities to fill their time."

Answer and Explanation

The Correct Answer is A

Choice A reason : Displaying a monthly calendar can help orient a client with Alzheimer's disease to the date and assist with maintaining a sense of time, which can be beneficial in managing cognitive impairment.

Choice B reason: Providing plenty of stimulation can be overwhelming for clients with Alzheimer's disease. A calm and predictable environment is usually more beneficial.

Choice C reason: Keeping the room dark at night can promote sleep, but it is not the only consideration. A nightlight or low-level lighting can prevent falls if the client needs to get up during the night.

Choice D reason: Providing structured activities can help fill the client's time and provide a sense of purpose, but it should be tailored to the individual's abilities and preferences.

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Correct Answer is B

Explanation

Choice A reason : Pressing down on the orbital area of the eye is not a recommended method for eliciting a response from a painful stimulus in an unresponsive patient due to the potential for injury to the eye.

Choice B reason : Pressing down on the trapezius muscle is an acceptable method for eliciting a response from a painful stimulus in an unresponsive patient. This technique is less invasive and can be performed safely to assess the patient's level of consciousness or response to pain without causing harm⁸.

Choice C reason : Using a 25-gauge needle is not an appropriate method for eliciting a response from a painful stimulus in an unresponsive patient. This could cause unnecessary harm and is not a standard practice in clinical settings.

Choice D reason : Eliciting a reflex with a reflex hammer is a method used to assess reflexes, not to elicit a response from a painful stimulus in an unresponsive patient. This tool is used to test neurological function and reflex integrity, not to assess pain response.

A. 150 mL of serosanguineous drainage B. 75 mL of greenish-yellow drainage C. 100 mL of red drainage D. 200 mL of brown drainage

Correct Answer is C

Explanation

Choice A reason: Serosanguineous drainage, which is a mixture of blood and a clear yellow liquid known as serum, is generally expected after surgery. While the amount of 150 mL may seem significant, it is not uncommon in the first hour postoperatively, especially after abdominal surgery. The nurse should continue to monitor the drainage and report if the volume increases significantly or if the drainage becomes bright red, indicating active bleeding.

Choice B reason: Greenish-yellow drainage is typically bile, which can be present in NG tube drainage after abdominal surgery. This type of drainage is not unusual and does not necessarily need to be reported unless accompanied by other concerning symptoms or changes in the patient's condition.

Choice C reason: 100 mL of red drainage is concerning and should be reported to the provider immediately. Red drainage suggests active bleeding, and in the context of the first postoperative hour, it could indicate a complication such as hemorrhage. Prompt assessment and intervention are required to address this potential emergency situation.

Choice D reason: Brown drainage may be old blood or could be related to the contents of the gastrointestinal tract. While 200 mL is a larger volume, brown drainage is not typically as concerning as bright red drainage. However, the nurse should monitor for changes in the color and consistency of the drainage, as well as the patient's vital signs and overall status.

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A nurse is providing teaching for the family of a client who has Alzheimer's disease. Which of the following statements should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is exhibiting an altered level of consciousness and is unresponsive to verbal stimuli. To elicit a response from a painful stimulus, the nurse would:

Correct Answer is B

Explanation

A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider?

Correct Answer is C

Explanation

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