An older adult in the middles 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

Answer and Explanation

The Correct Answer is C

A. Label the bathroom door: While labeling the bathroom door might be helpful in some cases, it may not be effective for a person with middle to late stages of Alzheimer's disease. They may have difficulty recognizing or interpreting written signs, and their memory and cognitive abilities may be severely impaired.
B. Take the older adult to the bathroom hourly: Taking the older adult to the bathroom hourly is a good practice to promote regular toileting. However, in the middle to late stages of Alzheimer's, the person may have significant cognitive impairment and may not always signal the need to use the bathroom. Additionally, it may not always be feasible to have someone available to assist hourly, and it may lead to caregiver burnout.
C. Place the older adult in disposable adult briefs: This is the most appropriate intervention in this situation. In the middle to late stages of Alzheimer's, individuals may have difficulty recognizing the need to use the toilet, and episodes of incontinence are common. Using disposable adult briefs helps maintain the person's dignity, prevents discomfort, and minimizes the risk of skin breakdown or infections due to incontinence.
D. Limit the intake of oral fluids to 1000 mL/day: Restricting fluid intake to such a low level is not recommended. Dehydration can have serious health consequences, and older adults, especially those with Alzheimer's, need to stay well-hydrated. Reducing fluid intake to this extent can lead to health complications and is not a suitable solution for addressing incontinence issues.

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Correct Answer is D

Explanation

Option A, "Institute reverse isolation," is not relevant to the situation. Reverse isolation is used to protect immunocompromised individuals from potential sources of infection.

Option B, "Withhold the next dose of medication," is not sufficient in this situation. Stopping the medication is a part of the response, but the client needs immediate medical attention.

Option C, "Begin high-protein, high-cholesterol diet," is not appropriate and does not address the client's current condition. NMS is a medical emergency, and dietary changes are not the primary intervention.

Option D. Notify the healthcare provider stat.

The client is experiencing symptoms that are suggestive of neuroleptic malignant syndrome (NMS), a potentially life-threatening condition that can occur as a rare side effect of antipsychotic medications like risperidone. NMS symptoms can include severe muscle stiffness, difficulty swallowing, drooling, diaphoresis (excessive sweating), and elevated vital signs, including fever.

A. Diaphoresis, piloerection, tremors, imitability, insomnia, nausea, and vomiting B. Diaphoresis, hypertension, hand tremors, hallucination/illusions, and potential seizures C. Cravings, Depression, fatigue, hypersomnolence, and impaired judgment D. Heightened sense of self, hallucinations, flashbacks, incoordination, and panic attacks

Correct Answer is A

Explanation

A. "Diaphoresis, piloerection, tremors, irritability, insomnia, nausea, and vomiting": These symptoms are indicative of opioid withdrawal. Opioid withdrawal symptoms typically include increased sweating (diaphoresis), goosebumps (piloerection), tremors, irritability, insomnia, nausea, and vomiting.
B. "Diaphoresis, hypertension, hand tremors, hallucinations/illusions, and potential seizures": These symptoms are not specific to opioid withdrawal but could be associated with withdrawal from other substances, such as alcohol or benzodiazepines. Opioid withdrawal symptoms do not typically include hypertension or seizures.
C. "Cravings, depression, fatigue, hypersomnolence, and impaired judgment": These symptoms may be associated with opioid withdrawal, but they are more related to the psychological and emotional aspects of withdrawal. The physical symptoms of opioid withdrawal are better represented by the symptoms in option A.
D. "Heightened sense of self, hallucinations, flashbacks, incoordination, and panic attacks": These symptoms do not typically represent opioid withdrawal. They might be more indicative of other conditions or substance use, but not opioid withdrawal.

In summary, option A represents the physical symptoms commonly associated with opioid withdrawal, including diaphoresis, piloerection, tremors, irritability, insomnia, nausea, and vomiting.

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An older adult in the middles 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is caring for a client who is withdrawing from long-term use of opioids. The nurse will monitor using a clinical opioid withdrawal screening Tool (COWS). Which of the following cluster of symptoms would indicate to the nurse the client was withdrawing from opioids?

Correct Answer is A

Explanation

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