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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Serum creatinine levels are commonly used to assess kidney function. While kidney function is important, it does not specifically evaluate nutritional status. Chronic alcohol use can impact multiple organs, but thiamine deficiency is a more direct concern related to nutritional status in these patients.

Choice B reason: Thiamine (vitamin B1) deficiency is a well-known complication of chronic alcohol use disorder. Alcohol interferes with the absorption and utilization of thiamine, leading to deficiencies that can cause severe neurological problems, such as Wernicke's encephalopathy and Korsakoff's syndrome. Monitoring thiamine levels is crucial in assessing and managing the nutritional status of clients with chronic alcohol use disorder.

Choice C reason: Urinalysis is a basic test that can provide information about kidney function and the presence of infections, among other things. However, it is not specifically useful in evaluating the nutritional status of a client with chronic alcohol use disorder. Nutritional deficiencies would not be directly assessed through a routine urinalysis.

Choice D reason: Erythrocyte sedimentation rate (ESR) is a non-specific marker of inflammation and is used to detect inflammatory conditions. While it can provide information on inflammatory processes, it does not directly assess nutritional status. The nutritional impact of chronic alcohol use disorder is more accurately evaluated by specific nutrient levels, such as thiamine.

A. Determine whether the client's goals are met. B. Collect data about the client's current health status. C. Provide the client with information on problem-solving. D. Establish a regular meeting time with the client.

Correct Answer is C

Explanation

Choice A reason: Determining whether the client's goals are met is part of the evaluation phase of the nurse-client relationship. This phase comes after the working phase and focuses on assessing the outcomes of the interventions and the progress made toward achieving the client's goals.

Choice B reason: Collecting data about the client's current health status is typically part of the assessment phase, which occurs at the beginning of the nurse-client relationship. During this phase, the nurse gathers comprehensive information about the client's physical, psychological, and social health to inform the care plan.

Choice C reason: Providing the client with information on problem-solving is an essential component of the working phase of the nurse-client relationship. During this phase, the nurse and client work collaboratively to address issues, develop coping strategies, and implement interventions aimed at improving the client's mental health. Teaching problem-solving skills helps empower the client to manage their condition effectively.

Choice D reason: Establishing a regular meeting time with the client is part of the orientation phase of the nurse-client relationship. In this initial phase, the nurse and client get to know each other, build rapport, and establish the parameters for the relationship, including setting up regular meetings.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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