A nurse is reviewing a patient’s medical record.
After reviewing the medical data, which of the following actions should the nurse plan to take?

Initiate seizure precautions.

Assist the patient to the bathroom.

Keep the patient’s head in a mid position.

Decrease oxygen to 1.5 L/min via nasal cannula.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Without specific patient data, it’s challenging to provide a detailed rationale.

However, initiating seizure precautions could be necessary if the patient’s medical record indicates a history of seizures or a condition that increases the risk of seizures.

Choice B rationale

Assisting the patient to the bathroom is a routine nursing intervention and would not typically be determined based on a review of the patient’s medical record.

Choice C rationale

Keeping the patient’s head in a mid position would depend on the patient’s condition and would not typically be determined based on a review of the patient’s medical record.

Choice D rationale

Decreasing oxygen to 1.5 L/min via nasal cannula would depend on the patient’s oxygen saturation levels and overall respiratory status.

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Correct Answer is A

Explanation

Choice A rationale

Participating in reminiscence therapy can be beneficial for patients with Alzheimer’s disease. This therapy involves discussing past experiences and life events, which can help improve mood, enhance communication, and maintain self-identity.

Choice B rationale

Raising all four side rails on a patient’s bed is not recommended. This can be considered a form of restraint and can increase the risk of injury if the patient attempts to climb over the rails. It’s important to promote a safe environment while respecting the patient’s rights.

Choice C rationale

Alternating the patient’s daily routine can be confusing and disorienting for individuals with Alzheimer’s disease. Maintaining a consistent routine can provide a sense of security and predictability.

Choice D rationale

Keeping the lights dimmed is not specifically beneficial for patients with Alzheimer’s disease. Adequate lighting can help prevent falls and other accidents. However, creating a calm and quiet environment can help reduce agitation.

A. Supine position B. Prone position C. Fowler’s position D. Trendelenburg position

Correct Answer is C

Explanation

Choice C rationale

Placing the client in Fowler's position (semi-upright position) facilitates optimal chest expansion and improves ventilation by allowing the diaphragm to move more effectively and reducing the pressure on the lungs from abdominal contents. This position helps in maximizing oxygenation and reducing respiratory distress. The other positions—supine, prone, and Trendelenburg—do not offer the same level of chest expansion and can exacerbate breathing difficulties.

The correct answer is to place the client in a position that allows for maximum chest expansion and oxygenation. This is often the upright or Fowler’s position.

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A nurse is reviewing a patient’s medical record.
After reviewing the medical data, which of the following actions should the nurse plan to take?