An older female resident of a long-term care facility with early-stage Alzheimer's disease frequently wanders into the wrong room. To help this client recognize her room, which intervention should the nurse implement?

Leave the door open so she recognizes her belongings.

Place a picture of the client on her door.

Put a bright red balloon on the client's door.

Enlarge the letters of her name on the door.

Answer and Explanation

The Correct Answer is B

Choice A reason: Leaving the door open so the client recognizes her belongings might help, but it is not the most effective solution. It relies on the client being able to remember and identify her possessions, which can be challenging with Alzheimer's disease.

Choice B reason: Placing a picture of the client on her door is an effective intervention. It provides a clear visual cue that the client can easily recognize, helping her to identify her own room without relying on memory alone. This approach uses a personal and familiar image, making it easier for the client to find her room.

Choice C reason: Putting a bright red balloon on the client's door may attract attention but does not provide a personal or meaningful cue for the client. While it might help distinguish the door, it lacks the personal connection needed for effective recognition.

Choice D reason: Enlarging the letters of her name on the door can help, but it still relies on the client's ability to read and recognize her name, which may be impaired. A picture of the client is a more straightforward and effective visual aid.

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Correct Answer is A

Explanation

Choice A reason: Administering IV furosemide (a diuretic) is crucial for managing the client's symptoms of fluid overload, as indicated by enema and elevated brain natriuretic peptide (BNP) levels. Furosemide helps reduce the volume of fluid in the body, relieving symptoms of heart failure and improving breathing. It addresses the most urgent need for the client.

Choice B reason: Inserting an indwelling urinary catheter might be necessary for accurate measurement of urine output, especially in a client receiving diuretic therapy. However, it is not the most immediate intervention needed to stabilize the client's condition.

Choice C reason: Monitoring for telemetry ST segment changes is important for clients with cardiac conditions. While it is necessary for ongoing assessment, it does not address the immediate need to relieve fluid overload and improve the client's respiratory status.

Choice D reason: Giving a bronchodilator per inhaler can help with respiratory symptoms related to emphysema. However, in this scenario, the primary issue is fluid overload due to heart failure, which needs to be addressed first with diuretic therapy.

A. Palpate the lymph nodes. B. Observe the client's fingers. C. Observe the skin for lesions. D. Palpate large joints for nodules.

Correct Answer is B

Explanation

Choice A reason: Palpating the lymph nodes is not a standard technique for assessing early signs of rheumatoid arthritis. Lymph node enlargement can occur due to various reasons, but it is not specific to rheumatoid arthritis.

Choice B reason: Observing the client's fingers is crucial because early signs of rheumatoid arthritis often present in the small joints of the hands and fingers. Symptoms such as swelling, redness, stiffness, and deformities can be evident in these areas.

Choice C reason: Observing the skin for lesions is not specific to rheumatoid arthritis. While some skin conditions can be associated with autoimmune diseases, rheumatoid arthritis primarily affects the joints.

Choice D reason: Palpating large joints for nodules might be relevant in more advanced stages of rheumatoid arthritis, but early signs are typically observed in the small joints of the hands and fingers.

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An older female resident of a long-term care facility with early-stage Alzheimer's disease frequently wanders into the wrong room. To help this client recognize her room, which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of emphysema and heart failure is admitted to the emergency department with enema, coughing, and shortness of breath. The client's laboratory value for brain natriuretic peptide is elevated. Which prescription is most important for the nurse to implement?

Correct Answer is A

Explanation

Which technique should the nurse use when assessing for early signs of rheumatoid arthritis?

Correct Answer is B

Explanation

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