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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 B

Explanation

Choice A rationale

Light therapy can be an effective treatment for certain conditions, like seasonal affective disorder, but it typically does not require informed consent unless it's experimental or has significant risks.

Choice B rationale

Experimental medications require informed consent due to the potential unknown effects and risks. Ensuring the client is fully informed about the experimental nature and possible side effects is crucial.

Choice C rationale

Participating in a group exercise program generally does not require informed consent. These activities are typically part of routine care and considered low risk.

Choice D rationale

Attending a cognitive behavioral therapy class usually does not require informed consent beyond the initial agreement to participate in therapy. These sessions are standard parts of mental health care.

A. I don't see a snake, but that must be scary for you. B. I'm using a syringe to obtain your blood, not a snake. C. Your provider requires this blood specimen. D. You must be mistaken.

Correct Answer is A

Explanation

Choice A rationale

Acknowledging the client's fear and providing reassurance without confirming the hallucination helps build trust and reduce anxiety.

Choice B rationale

Correcting the client by stating it is a syringe, not a snake, dismisses their fear and can increase distress.

Choice C rationale

Emphasizing the provider's requirement for the blood specimen does not address the client's fear and can worsen anxiety.

Choice D rationale

Telling the client they are mistaken dismisses their hallucination and can increase their distress and mistrust.

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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 contributing to the plan of care for a client who has bipolar disorder and whose admission was voluntary.For which of the following interventions should the nurse confirm that the client has given informed consent?

Correct Answer is B

Explanation

A nurse in a mental health facility is collecting a blood specimen from a client.The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood.”. Which of the following responses should the nurse make?

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?