An older client with Alzheimer's disease is confused and asking the nurse to call their mother who is deceased. Which nonpharmacological intervention should the nurse implement?
Clarify reality with the client about delusional thoughts.
Reduce the client's interaction with others during day.
Use distraction and therapeutic communication skills.
Awaken the client for reality checks every 4 hours at night.
The Correct Answer is C
A) Incorrect- Clarify reality with the client about delusional thoughts: Attempting to correct the client's delusional thoughts might cause frustration and agitation. Clients with Alzheimer's disease may have difficulty comprehending and retaining reality-based information.
B) Incorrect- Reduce the client's interaction with others during the day: Social interaction is important for clients with Alzheimer's disease to maintain engagement and prevent feelings of isolation. Reducing interaction could worsen their emotional well-being.
C) Correct- Clients with Alzheimer's disease often experience cognitive impairments and may have delusional thoughts or confusion, such as believing deceased loved ones are still alive. Nonpharmacological interventions are crucial to provide comfort and manage challenging behaviors. Distraction techniques involve redirecting the client's attention away from the delusion and onto a different, engaging activity. This can help decrease distress and anxiety related to their delusional thoughts. Therapeutic communication skills, such as validating the client's feelings and emotions, can also be beneficial. Simply telling the client that their mother is deceased may cause distress and confusion. Instead, providing comfort, empathizing with their emotions, and redirecting their focus can be more effective in managing the situation.
D) Incorrect- Awaken the client for reality checks every 4 hours at night: Disrupting the client's sleep schedule could lead to increased confusion and restlessness. It's important to provide a calm and consistent sleep routine for individuals with Alzheimer's disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
This breakfast selection is the most appropriate for a 16-year-old with diarrhea. Oatmeal is a bland and easily digestible food that can help to firm up the stool. Bananas are a good source of potassium and can help replace electrolytes that may be lost through diarrhea. Herbal tea is a non-caffeinated option that can help to soothe the digestive system. It is important to avoid foods that are greasy, high in fat, or spicy, as they can worsen diarrhea symptoms.
Correct Answer is ["A","B","C","D","E"]
Explanation
It is important to assess the child's vital signs, including oxygen saturation (SaO2), to ensure their stability and identify any signs of respiratory distress or other abnormalities that may impact medication administration.
Prior to administering any medication, it is crucial to verify if the child has any known allergies to medications. This information is essential for ensuring the safety of the child and preventing any potential allergic reactions.
Before administering pain medication, the nurse must verify that the prescribed dosage is appropriate for the child's age, weight, and condition. Ensuring the correct dosage helps prevent medication errors and potential adverse effects.
It is important to use a validated pain assessment tool that is appropriate for the child's age and cognitive abilities. This allows for a comprehensive and accurate assessment of the child's pain level, helping guide appropriate pain management interventions.
Considering the child has cognitive and speech delays, the input from the parent regarding the child's pain is valuable. The nurse should assess and consider the parent's report of the child's pain in conjunction with other assessment findings to ensure effective pain management.
Subjective pain assessment is mentioned as a finding but may not require immediate action, as it needs to be combined with other assessment data for a comprehensive evaluation.
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