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?

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.

Ask the patient why the wandering episodes have occurred.

Answer and Explanation

The Correct Answer is A

Choice A reason: Placing the patient near the nurse’s station allows close monitoring, reducing wandering risks in Alzheimer’s disease. This aligns with safety protocols in rehab facilities, making it the correct action to include in the care plan to manage the patient’s wandering behavior effectively.

Choice B reason: Reorienting frequently may not prevent wandering in Alzheimer’s, as cognitive deficits persist. Proximity to the nurse’s station ensures safety, making this less effective and incorrect compared to the nurse’s priority of physical monitoring to address the patient’s wandering risk.

Choice C reason: Familiar items provide comfort but don’t directly prevent wandering, a safety concern in Alzheimer’s. A room near the nurse’s station is more effective, making this secondary and incorrect compared to the nurse’s focus on immediate safety in the care plan.

Choice D reason: Asking why the patient wanders is ineffective, as Alzheimer’s impairs insight into behavior. Close monitoring via room placement prevents wandering, making this impractical and incorrect compared to the nurse’s action to ensure safety in the rehab facility care plan.

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Correct Answer is C

Explanation

Choice A reason: Hyperactivity and agitation characterize hyperactive delirium, not hypoactive, which involves lethargy. Reduced alertness is typical, making this incorrect, as it describes the opposite presentation of hypoactive delirium in the nurse’s assessment of the patient’s mental status.

Choice B reason: Hallucinations and delusions are more common in hyperactive or mixed delirium, not hypoactive, which features withdrawal. Lethargy is expected, making this incorrect, as it does not align with the typical findings in hypoactive delirium during the nurse’s evaluation.

Choice C reason: Lethargy and reduced alertness define hypoactive delirium, with patients appearing withdrawn or sleepy. This aligns with delirium assessment criteria, making it the correct finding the nurse would expect in a patient diagnosed with hypoactive delirium in a clinical setting.

Choice D reason: Combative behavior and shouting indicate hyperactive delirium, not hypoactive, which is marked by lethargy. Reduced alertness is the correct finding, making this incorrect, as it misrepresents the subdued presentation of hypoactive delirium in the nurse’s patient assessment.

A. The patient has difficulty speaking. B. There are fine crackles at the lung bases. C. The pulse rate is 102 beats/min. D. The blood pressure is 144/86 mm Hg.

Correct Answer is A

Explanation

Choice A reason: Difficulty speaking post-carotid artery angioplasty suggests a neurological complication, possibly stroke, requiring immediate intervention. This aligns with post-procedure neurological assessment priorities, making it the most concerning finding for the nurse to address urgently in the patient’s care.

Choice B reason: Fine crackles at lung bases may indicate fluid overload but are less urgent than speech difficulty, which suggests stroke. Neurological complications take precedence, making this secondary and incorrect compared to the nurse’s priority of addressing potential cerebral events post-procedure.

Choice C reason: A pulse of 102 beats/min is mildly elevated but less critical than speech difficulty, which may indicate a neurological event. Stroke risk is the primary concern, making this less urgent and incorrect compared to the nurse’s focus on neurological assessment post-angioplasty.

Choice D reason: Blood pressure of 144/86 mm Hg is elevated but within acceptable post-procedure ranges. Speech difficulty suggests a neurological issue, making this less concerning and incorrect compared to the nurse’s priority of evaluating potential stroke in the patient post-angioplasty.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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