A nurse is providing teaching to the caregivers of a client who has Alzheimer's disease and wanders during the night about safety. Which of the following recommendations should the nurse make?
Encourage the client to rest during the day.
Ask the client why they continue to get out of bed.
Move the client's mattress to the floor.
Keep a television on at night in the client's room.
The Correct Answer is C
Choice A reason: Encouraging the client to rest during the day is not appropriate. Daytime rest can worsen nighttime wakefulness and wandering. Clients with Alzheimer’s benefit from structured daytime activity to promote nighttime sleep.
Choice B reason: Asking the client why they continue to get out of bed is ineffective. Clients with Alzheimer’s often cannot provide logical explanations due to cognitive decline. This approach does not enhance safety.
Choice C reason: Moving the mattress to the floor is correct because it reduces the risk of injury if the client attempts to get out of bed or falls. This is a practical safety intervention for clients who wander or are restless at night.
Choice D reason: Keeping a television on at night introduces noise and light, which can increase agitation and confusion. It disrupts sleep and does not prevent wandering.
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Correct Answer is D
Explanation
Choice A reason: Continuing CPR until the provider arrives disregards the client’s DNR order. This violates the client’s autonomy and legal rights.
Choice B reason: Notifying the ethics committee is not an immediate action. Ethics committees provide guidance in complex cases but are not involved in urgent bedside decisions.
Choice C reason: Contacting the family to determine what they would like done is inappropriate. The client’s advance directive takes precedence over family wishes.
Choice D reason: Stopping CPR and informing the nurse of the client’s advance directives is correct. A DNR order legally and ethically directs healthcare providers to withhold resuscitation. Respecting this ensures the client’s wishes are honored and prevents unnecessary interventions.
Correct Answer is C
Explanation
Choice A reason: Administering an IV diuretic is important to reduce fluid overload, but it is not the immediate priority. Diuretics take time to act, and the client’s oxygenation must be stabilized first.
Choice B reason: Requesting an analysis of ABGs provides valuable diagnostic information, but it is not the priority intervention. ABG analysis does not directly improve oxygenation or relieve symptoms in the acute phase.
Choice C reason: Initiating oxygen via face mask is the priority because pulmonary edema impairs gas exchange, leading to hypoxemia. Immediate oxygen administration improves oxygen saturation and prevents tissue hypoxia while other interventions are prepared.
Choice D reason: Inserting an indwelling urinary catheter may be necessary for monitoring urine output when diuretics are administered, but it is not urgent compared to restoring oxygenation.
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