A patient with Alzheimer's disease (AD) who is being admitted to a hospital rehab facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care?
Ask the patient why the wandering episodes have occurred
Place the patient in a room close to the nurse's station
Reorient the patient several times daily
Have the family bring in familiar items
The Correct Answer is B
Choice A reason: Asking the patient why the wandering episodes have occurred might not be effective because patients with Alzheimer's disease often have memory and cognitive impairments that make it difficult for them to understand or articulate the reasons for their behavior. Additionally, it may not address the immediate safety concerns associated with wandering.
Choice B reason: Placing the patient in a room close to the nurse's station is a practical and effective measure to enhance patient safety. Proximity to the nurse's station allows for closer supervision and quicker response if the patient attempts to wander. This action helps prevent potential accidents and ensures that the patient receives timely interventions if needed. It is a proactive approach to managing the wandering behavior commonly seen in patients with Alzheimer's disease.
Choice C reason: Reorienting the patient several times daily is an important aspect of care for individuals with Alzheimer's disease, as it can help reduce confusion and anxiety. However, this alone may not be sufficient to prevent wandering. While reorientation is beneficial, the immediate safety of the patient requires additional measures, such as close supervision.
Choice D reason: Having the family bring in familiar items can provide comfort and a sense of security for the patient, which is important in managing Alzheimer's disease. Familiar objects may help reduce anxiety and agitation, but they do not directly address the safety concerns associated with wandering. This action should be part of a comprehensive care plan that includes measures to prevent wandering and ensure patient safety.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Administering furosemide in this scenario would further lower the serum potassium level, as furosemide is a loop diuretic known for causing potassium loss through urine. This action could worsen the patient’s hypokalemia, leading to severe complications such as cardiac arrhythmias. Therefore, administering furosemide in the presence of hypokalemia is inappropriate and could put the patient at significant risk.
Choice B reason:
Administering both spironolactone and furosemide together without addressing the hypokalemia would not be safe. While spironolactone is a potassium-sparing diuretic, combining it with furosemide could negate its potassium-sparing effects. Furthermore, administering furosemide when hypokalemia is present could cause further electrolyte imbalance. Proper evaluation of the patient's condition and selective administration of the medications are crucial in this case.
Choice C reason:
Withholding both medications and attributing the decision to contraindications with hyperkalemia is incorrect because the reported potassium level (3.2 mEq/L) reflects hypokalemia, not hyperkalemia. Misinterpreting the lab result could delay appropriate treatment, such as correcting the potassium level or safely administering a medication that would not exacerbate the hypokalemia. Proper communication with the healthcare provider is necessary for effective patient care.
Choice D reason:
Administering spironolactone is the best action in this scenario because it is a potassium-sparing diuretic. By administering spironolactone, the risk of worsening hypokalemia is minimized. Notifying the healthcare provider about the low potassium level ensures appropriate monitoring and any necessary interventions, such as potassium supplementation. This approach is both safe and effective in managing the patient’s current condition while adhering to standard nursing practices.
Correct Answer is B
Explanation
Choice A reason:
Receiving a blood transfusion after 1992 does not strongly indicate the need for hepatitis C screening because screening of blood products for hepatitis C became standard practice in the early 1990s. By 2005, the risk of transmission via transfusion had been effectively eliminated. Therefore, while a past transfusion may be part of the patient's health history, it does not necessitate hepatitis C screening in this case.
Choice B reason:
Intravenous drug use, even if it occurred 20 years ago, is a significant risk factor for hepatitis C infection. The virus is commonly transmitted through the sharing of needles or other equipment used to inject drugs. Due to the long latency period of hepatitis C, individuals with a history of IV drug use are at high risk and should be screened regardless of how long ago the exposure occurred. This is the most relevant information in the patient’s history to prompt screening.
Choice C reason:
Frequent dining in fast-food restaurants does not indicate a risk for hepatitis C. Hepatitis C is primarily spread through blood-to-blood contact, not through food or drink. This choice reflects a misunderstanding of the transmission pathways of hepatitis C and is irrelevant to the patient’s screening needs.
Choice D reason:
Traveling to a country with poor sanitation is more associated with the risk of hepatitis A, a virus that is often spread through contaminated water or food. Hepatitis C, however, is not typically transmitted via poor sanitation or contaminated food and water. Screening for hepatitis C would not be warranted based solely on travel history to such countries.
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