A nurse is reinforcing teaching about home care with the family of a client who has Alzheimer's disease and wanders at night. Which of the following instructions should the nurse include?
Keep the client's bedroom area dark at night.
Have the client exercise 30 minutes before bedtime.
Place the client's mattress on the bedroom floor.
Encourage the client to nap often during the day.
The Correct Answer is C
Choice A reason: Keeping the client's bedroom area dark at night is not advisable for individuals with Alzheimer's disease who wander. Darkness can increase confusion and the risk of falls. It is better to have a night light or dim lighting to help the client navigate safely if they get up during the night. Proper lighting can reduce disorientation and provide a safer environment for those who wander.
Choice B reason: Having the client exercise 30 minutes before bedtime is not recommended. Exercise close to bedtime can be stimulating and might make it more difficult for the client to fall asleep. It is generally advised to avoid vigorous physical activity at least a few hours before bedtime to promote better sleep. Gentle activities earlier in the day can help improve sleep quality without causing overstimulation.
Choice C reason: Placing the client's mattress on the bedroom floor is a practical safety measure for clients with Alzheimer's disease who wander at night. This approach minimizes the risk of injury from falls, as the client will be closer to the ground. By reducing the height of the bed, families can create a safer sleeping environment and help prevent potential injuries due to wandering and confusion.
Choice D reason: Encouraging the client to nap often during the day can disrupt nighttime sleep patterns. Excessive daytime napping can lead to difficulties falling asleep at night and contribute to nighttime wandering. It is essential to maintain a balanced routine with limited napping during the day to promote better sleep at night. Structured activities and proper sleep hygiene can help improve nighttime rest.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Hypoactive bowel sounds can indicate a variety of gastrointestinal issues, but they are not typically associated with haloperidol use. While it is important to monitor bowel sounds, it is not the priority in this context.
Choice B reason: Dry mouth is a common side effect of many medications, including haloperidol. While it can be uncomfortable for the client, it is not usually a serious concern and can be managed with hydration and other supportive measures.
Choice C reason: Constant opening and closing of the mouth, also known as tardive dyskinesia, is a serious side effect of haloperidol and other antipsychotic medications. This condition involves involuntary muscle movements and can be irreversible. It is crucial to report this finding to the provider immediately for assessment and potential adjustment of the medication regimen.
Choice D reason: Photosensitivity is not a common side effect of haloperidol. While it is important to monitor for any new or unusual symptoms, photosensitivity is not typically associated with this medication.
Correct Answer is C
Explanation
Choice A reason: Setting limits is not typically the primary behavioral management technique for clients with delirium. Delirium is an acute and often reversible state of confusion that requires addressing the underlying medical cause. Management strategies for delirium focus on reorientation, ensuring safety, and treating any underlying conditions rather than setting behavioral limits.
Choice B reason: Clients with depression may benefit from supportive and empathetic interactions rather than strict behavioral limits. While structure and routine can be helpful, the primary approach for managing depression involves therapeutic communication, medication management, and cognitive-behavioral strategies rather than setting limits on behavior.
Choice C reason: Setting limits is an essential behavioral management technique for clients with antisocial personality disorder. Individuals with this disorder often exhibit manipulative, deceitful, and aggressive behaviors. Clear and consistent limits help establish boundaries and prevent the exploitation of others. This approach promotes accountability and helps manage inappropriate behaviors in a therapeutic setting.
Choice D reason: Generalized anxiety disorder is characterized by excessive and persistent worry. Behavioral management techniques for anxiety disorders typically include cognitive-behavioral therapy, relaxation techniques, and sometimes medication. Setting limits is not a primary intervention for managing anxiety; rather, the focus is on reducing anxiety symptoms through therapeutic strategies.
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