A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Place the client in a reclining chair.

Put locks at top of doors.

Encourage physical activity prior to bed time.

Position the mattress on the floor.

Install sensor devices on outside doors.

Answer and Explanation

Correct Answer : B,C,D,E

A.   Placing the client in a reclining chair is not recommended as it does not prevent wandering or falls and may even restrict movement leading to discomfort or pressure sores.
B.   Putting locks at the top of doors can prevent the client from wandering outside, which reduces the risk of falls and getting lost, especially during the night.
C.   Encouraging physical activity prior to bedtime can help in expending energy which may lead to better sleep and reduce restlessness and wandering at night.
D.   Positioning the mattress on the floor can minimize injury from falls that may occur when the client attempts to get out of bed during the night.
E.   Installing sensor devices on outside doors can alert the caregiver if the client attempts to leave the house, which is crucial for preventing wandering and potential falls.

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Correct Answer is B

Explanation

- Choice A Rationale: This statement does not indicate spiritual distress. On the contrary, it suggests that the client's faith is a source of strength and hope, which is typically a sign of positive spiritual well-being.
- Choice B Rationale:

This statement suggests a disruption in the client's spiritual practices, which could lead to spiritual distress as it interferes with a meaningful coping mechanism.

- Choice C Rationale: Similar to choice A, this statement reflects a positive aspect of the client's spirituality. Finding comfort in meditation is indicative of a beneficial spiritual practice and does not suggest distress.
- Choice D Rationale:

This reflects active spiritual support, which is helpful during illness and not indicative of spiritual distress.

A. Participation in group therapy B. Movement through the stages of grief C. Client resolves to limit alcohol consumption D. Appetite E. Cognition F. Vital signs

Correct Answer is ["A","B","E","F"]

Explanation

A. Participation in group therapy - This indicates the client's engagement in therapeutic interventions, suggesting progress in addressing their alcohol use disorder and coping with grief.
B. Movement through the stages of grief - Progress in processing grief is a positive sign of emotional healing and adjustment.
C. Client resolves to limit alcohol consumption - While resolution to limit alcohol consumption would be an ideal outcome, there is no specific indication in the scenario that the client has made this resolution.
D. Appetite - Although improvement in appetite would be a positive sign, there is no specific mention of the client's appetite in the provided information, so it cannot be assumed that this finding indicates progress in the client's plan of care.
E. Cognition - Improvement in cognition suggests a reduction in the effects of alcohol intoxication or withdrawal, indicating progress in treatment.
F. Vital signs - Stable vital signs within normal range suggest physiological stability and potentially a positive response to treatment.

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A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the spiritual beliefs of a client. Which of the following client statements indicates spiritual distress?

Correct Answer is B

Explanation

A nurse is reviewing the day 5 vital signs and nurses' notes. Exhibits A nurse is evaluating the client's response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.

Correct Answer is ["A","B","E","F"]

Explanation

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