An older adult in the middle and late stages of Alzheimer's forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the client's family?
Label the bathroom door.
Take the older adult to the bathroom hourly.
Place the older adult in disposable adult briefs.
Limit the intake of oral fluids to 1000 mL/day.
The Correct Answer is A
A. Labeling the bathroom door can provide a visual cue to help the older adult locate the bathroom, which may reduce episodes of incontinence.
B. Taking the older adult to the bathroom hourly is a good strategy, but it may not always be feasible or effective in preventing accidents.
C. Using disposable adult briefs may be necessary at times, but it should not be the first line intervention.
D. Limiting oral fluids to 1000 mL/day may lead to dehydration and is not an appropriate intervention for addressing incontinence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "He may begin to try to cover recognition of his memory loss by creating events." As
dementia progresses, individuals may experience confabulation, which involves creating false memories to compensate for memory loss. This is a common symptom seen in the middle stages of dementia.
B. "He may have difficulty in a motor skill such as walking." While motor skills may be affected in the later stages of dementia, it is not typically one of the early signs.
C. "The inability to communicate with speech comes immediately after the early signs." This statement is not accurate. Communication difficulties may occur in later stages, but it is not an immediate progression from early signs.
D. "He may not recognize you and other people who have been in his life." This symptom, known as agnosia, may occur in later stages of dementia, but it is not one of the early signs.
Correct Answer is D
Explanation
A) Incorrect. Reverse isolation is not indicated in this situation. The client's symptoms are likely due to a side effect of the medication, not an infectious process.
B) Incorrect. While it may be necessary to withhold the next dose of medication, the client's symptoms require more immediate attention.
C) Incorrect. The client's symptoms are indicative of a serious adverse reaction, and dietary changes would not address the issue.
D) Correct. The client's symptoms, including severe muscle stiffness, difficulty swallowing, drooling, diaphoresis, and elevated vital signs, are indicative of neuroleptic malignant syndrome (NMS), a potentially life-threatening side effect of antipsychotic medications like risperidone.
The nurse should notify the healthcare provider immediately for further guidance and intervention.
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