A nurse is reinforcing teaching with the caregiver of a client who has Alzheimer's disease.
The caregiver reports that the client awakens at night and wanders.
Which of the following strategies should the nurse suggest?
Place a lock at the top of doors leading outside.
Use light restraints while the client is in bed.
Administer an antianxiety medication before bedtime.
Encourage the client to nap during the day.
The Correct Answer is A
Choice A rationale
Placing a lock at the top of doors helps prevent the client from wandering outside, ensuring safety.
Choice B rationale
Using light restraints is not recommended due to ethical concerns and potential harm.
Choice C rationale
Administering antianxiety medication should not be the first strategy due to potential side effects and over-medication.
Choice D rationale
Encouraging napping during the day may worsen nighttime wakefulness and wandering.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Increasing the client's daily caloric intake is not an intervention specifically recommended for clients taking lithium. Lithium therapy requires monitoring of fluid and electrolyte balance, but there is no specific recommendation to increase caloric intake as part of the treatment plan.
Choice B rationale
Administering lithium with meals is recommended to reduce gastrointestinal upset. Lithium can cause stomach irritation, and taking it with food helps minimize this side effect, improving the client's comfort and adherence to the medication regimen.
Choice C rationale
Monitoring for hypoglycemia is not a standard intervention for clients taking lithium. Lithium primarily affects fluid and electrolyte balance, particularly sodium levels, but it is not associated with causing hypoglycemia. Monitoring for lithium toxicity and maintaining appropriate hydration are more critical aspects of care.
Choice D rationale
Decreasing dietary potassium is not required for clients taking lithium. Lithium does not affect potassium levels significantly, and there is no need to modify potassium intake. The focus should be on maintaining adequate hydration and monitoring lithium levels to avoid toxicity.
Correct Answer is D
Explanation
Choice A rationale
Therapeutic holds involve physical restraint, which is not a de-escalation technique. It is a last resort when a client poses immediate harm.
Choice B rationale
Restraints are not de-escalation techniques; they are measures taken when other interventions have failed.
Choice C rationale
Diversion involves redirecting the client's attention, but it does not allow the client to process their emotions in a controlled environment.
Choice D rationale
Timeout allows the client to have a moment away from stimuli to regain control and calm down, which is a recognized de-escalation technique.
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