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 D

Explanation

Choice A reason: Naltrexone is not designed to prevent alcohol withdrawal symptoms. It works by blocking the euphoric effects of alcohol and reducing cravings, but clients who stop drinking may still experience withdrawal symptoms. Proper medical management and support are necessary to address alcohol withdrawal.

Choice B reason: Naltrexone does not help clients gradually decrease alcohol intake. Instead, it is used to help maintain abstinence by reducing cravings and the reinforcing effects of alcohol. Clients typically need to stop drinking before starting naltrexone treatment.

Choice C reason: Ringing in the ears, or tinnitus, is not a common side effect of naltrexone or an expected reaction when consuming alcohol while on the medication. This statement indicates a misunderstanding of how naltrexone works and its potential side effects.

Choice D reason: This statement accurately reflects one of the primary effects of naltrexone. The medication helps reduce cravings for alcohol, making it easier for individuals to maintain abstinence and avoid relapse. By understanding this aspect of naltrexone, the client demonstrates a clear understanding of its purpose and use in alcohol dependence treatment.

A. Use a quick-release tie to restrain the client. B. Renew the restraint prescription every 48 hr. C. Attach the restraints to the side rail of the client's bed. D. Maintain 1 fingerbreadth between the restraint and the client's skin.

Correct Answer is A

Explanation

Choice A reason: Using a quick-release tie for restraints ensures that the nurse can quickly and easily release the client in case of an emergency. Quick-release ties are designed to provide safety and convenience, allowing healthcare providers to promptly respond to the client's needs without compromising safety. This method reduces the risk of injury to both the client and the healthcare team.

Choice B reason: Restraint prescriptions typically need to be renewed more frequently than every 48 hours, often within 24 hours. The exact duration depends on the facility's policy and regulatory guidelines. Regular assessment of the need for restraints and timely renewal of the prescription ensure that restraints are used appropriately and only as long as necessary.

Choice C reason: Attaching restraints to the side rail of the client's bed is unsafe and inappropriate. Restraints should be attached to a non-movable part of the bed frame to prevent the client from injuring themselves if the side rail is moved. Securing restraints to a stable part of the bed ensures better control and reduces the risk of harm.

Choice D reason: While maintaining some space between the restraint and the client's skin is important to prevent circulation issues, the guideline typically suggests maintaining two fingers' breadth between the restraint and the client's skin, not one. This ensures adequate circulation and reduces the risk of injury or skin breakdown.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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