A nurse provides home safety education to the family of a client with moderate Alzheimer's. Which of the following statements made by the primary caregiver indicates effective teaching?

"We will use the antipsychotics around the clock"

"She will not be left home alone

"I will apply the restraint to only one wrist".

"Rugs will be put in the bathroom to help her identify where she is "

Answer and Explanation

The Correct Answer is B

Choice A Rationale: Using antipsychotics around the clock is not an appropriate approach for managing Alzheimer's disease and may have adverse effects.

Choice B Rationale: "She will not be left home alone" indicates effective teaching because it emphasizes the importance of supervision and safety for a client with Alzheimer's who may be at risk of wandering or accidents.

Choice C Rationale: Applying a restraint to only one wrist is not an appropriate or effective strategy for managing Alzheimer's-related behaviors and may have ethical concerns.

Choice D Rationale: Placing rugs in the bathroom may create tripping hazards for a client with Alzheimer's. Effective teaching should focus on removing hazards rather than adding them.

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Correct Answer is A

Explanation

Choice A Rationale: Assessing the client for bladder distention is the first and most crucial step in managing autonomic dysreflexia. Bladder distention is a common trigger for this condition in clients with spinal cord injuries. Identifying and addressing the cause (bladder distention) is the priority to prevent further complications.

Choice B Rationale: Laying the client flat may not resolve the underlying cause of autonomic dysreflexia and should be done after identifying and addressing the trigger.

Choice C Rationale: Obtaining the client's heart rate is important but should come after assessing for bladder distention since the primary concern in autonomic dysreflexia is elevated blood pressure due to a noxious stimulus.

Choice D Rationale: Administering a nitrate antihypertensive may be necessary if other interventions do not resolve the blood pressure elevation, but it should not be the first action. Identifying and addressing the cause, such as bladder distention, is the priority.

A. A measure the calves for symmetry B. B palpate the bladder C. C Place a pillow between the knees and ankles D. D Check the gag reflex

Correct Answer is C

Explanation

Choice A Rationale: Measuring the calves for symmetry is not directly related to preventing complications after repositioning.

Choice B Rationale: Palpating the bladder is important for assessing urinary retention but is not the immediate action to prevent complications after repositioning.

Choice C Rationale: Placing a pillow between the knees and ankles is the correct action to prevent complications such as pressure ulcers and skin breakdown when a client is in a side-lying position.

Choice D Rationale: Checking the gag reflex is unrelated to repositioning and preventing complications.

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A nurse provides home safety education to the family of a client with moderate Alzheimer's. Which of the following statements made by the primary caregiver indicates effective teaching?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A client who suffered partial paralysis is repositioned by the nurse every 2 hours. After placing the client in a side-lying position, what action will nurse take to prevent complications?

Correct Answer is C

Explanation

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