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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E","F"]
Explanation
Choice A reason: A tongue blade is not typically necessary for a patient with status epilepticus. It is more commonly used for oral care or to check the throat, but it is not essential in this context.
Choice B reason: A urinary catheter is not necessary unless the patient has specific urinary retention issues or requires accurate measurement of urine output. It is not standard equipment for managing status epilepticus.
Choice C reason: A nasogastric tube is not typically required for status epilepticus unless there are specific gastrointestinal issues that need to be addressed. It is not standard equipment for managing status epilepticus.
Choice D reason: A suction set up is essential for a patient with status epilepticus to manage potential airway secretions and prevent aspiration. It ensures that the airway remains clear and reduces the risk of complications.
Choice E reason: An oxygen mask is crucial for a patient with status epilepticus to ensure adequate oxygenation. It helps maintain oxygen levels and supports respiratory function, especially if the patient experiences respiratory distress.
Choice F reason: Side-rail pads are important for patient safety, particularly for a patient with status epilepticus who may be at risk of falls or injury during seizures. They provide a protective barrier and help prevent accidental injury.
Correct Answer is C
Explanation
Choice A reason: Decreasing blood glucose levels are not an indicator of effective therapy in patients with acute adrenal insufficiency. In fact, hypoglycemia is a common symptom of Addison's Disease due to insufficient cortisol production, and effective therapy would aim to normalize blood glucose levels, not decrease them further.
Choice B reason: Increasing serum potassium levels would indicate worsening of the condition rather than improvement. Hyperkalemia is a hallmark of Addison's Disease due to aldosterone deficiency, and effective therapy should decrease serum potassium levels, not increase them.
Choice C reason: Increasing serum sodium levels would indicate that the therapy is effective for acute adrenal insufficiency. Addison's Disease is characterized by hyponatremia due to aldosterone deficiency, and effective treatment aims to normalize sodium levels in the blood. An increase in serum sodium levels indicates that the treatment is correcting the underlying electrolyte imbalance.
Choice D reason: Decreasing serum chloride levels are not a specific indicator of effective therapy for Addison's Disease. Chloride levels are generally less affected and not a primary marker for assessing treatment efficacy. The main focus should be on correcting sodium and potassium imbalances.
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