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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.

Answer and Explanation

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.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion: Expected. The client has dehydration (dry mucous membranes, dark yellow urine, history of alcohol-related cirrhosis), so IV fluids are appropriate.
Administer lorazepam: Expected. Lorazepam may be used for agitation and/or alcohol withdrawal symptoms, especially considering the client’s history of alcohol use.
Initiate 1:1 supervision: Expected. The client is confused, agitated, and experiencing delirium, which increases the risk of harm to self or others.
Administer acyclovir: Unexpected. Acyclovir is used for viral infections such as herpes, and there is no evidence in the scenario to suggest a viral etiology for the client’s delirium or symptoms.

A. Implement 24-hr one-to-one nursing observation. B. Document the client's behavior every 2 hr. C. Restrict interactions with other clients. D. Administer prescribed medication via the IM route.

Correct Answer is A

Explanation

Choice A rationale

Implementing 24-hr one-to-one nursing observation is crucial for ensuring the safety of a client who has overdosed and is at risk of self-harm.

Choice B rationale

Documenting the client's behavior every 2 hr is not sufficient to ensure their safety in an overdose situation.

Choice C rationale

Restricting interactions with other clients does not directly address the immediate risk of harm to the client.

Choice D rationale

Administering prescribed medication via the IM route does not provide the necessary supervision for a client at high risk of self-harm.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 65-year-old male client in the emergency department (ED). Exhibits For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication.The client has prescriptions for an anxiolytic and an SSRI antidepressant.Which of the following precautions should the nurse take?

Correct Answer is A

Explanation

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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?

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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?