Behavior problems such as resisting care, pulling tubes or dressings, yelling, or wandering off can occur in patients with Alzheimer disease (AD). Select 4 appropriate nursing interventions for maintaining safety in patient with (AD). (Select all that apply)
Assess the patient’s physical status.
Keep the door of the patient’s room closed.
Place the patient in a room at the end of the hall so that their yelling does not disturb the other patients.
Assess for pain.
Check for changes in vital signs.
Apply wrist restraints.
Cover tubes and IV lines with stretch tube gauze or remove them from the visual field.
Correct Answer : A,D,E,G
Choice A reason: Assessing physical status identifies triggers like discomfort or illness causing Alzheimer’s behavior, enhancing safety. This aligns with patient-centered care, making it a correct intervention the nurse would use to maintain safety by addressing underlying causes of agitation or wandering.
Choice B reason: Keeping the door closed may trap the patient, increasing agitation, not safety. Covering IV lines reduces tampering, making this incorrect, as it’s less effective than the nurse’s focus on interventions that address behavior triggers in Alzheimer’s disease safely.
Choice C reason: Isolating the patient at the hall’s end ignores behavior causes and reduces monitoring, compromising safety. Pain assessment is better, making this incorrect, as it doesn’t align with the nurse’s goal of maintaining safety through active behavioral management in Alzheimer’s.
Choice D reason: Assessing for pain identifies treatable causes of agitation or resistance in Alzheimer’s, promoting safety. This aligns with behavioral management, making it a correct intervention the nurse would implement to reduce unsafe behaviors like pulling tubes or wandering off.
Choice E reason: Checking vital signs detects physiological changes contributing to Alzheimer’s behaviors, ensuring safety. This aligns with comprehensive assessment, making it a correct intervention the nurse would use to monitor and address factors increasing risks like yelling or resisting care.
Choice F reason: Wrist restraints increase agitation and risk injury in Alzheimer’s, reducing safety. Covering tubes is safer, making this incorrect, as it contradicts the nurse’s priority of using non-restrictive interventions to manage behavior and maintain safety in these patients.
Choice G reason: Covering IV lines or tubes reduces tampering by Alzheimer’s patients, enhancing safety without restraints. This aligns with environmental management, making it a correct intervention the nurse would implement to prevent unsafe behaviors like pulling dressings or tubes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Upper GI bleeding causes hypovolemia, not right heart failure, which results from lung-related pressure. COPD is the cause, making this incorrect, as it doesn’t align with the nurse’s recognition of cor pulmonale’s etiology linked to chronic lung conditions.
Choice B reason: Liver failure leads to ascites or varices, not cor pulmonale, which is driven by pulmonary hypertension from lung disease. COPD is correct, making this incorrect, as it misattributes the cause of right heart failure to a non-pulmonary condition.
Choice C reason: COPD causes pulmonary hypertension, leading to right heart failure (cor pulmonale) due to chronic lung strain. This aligns with cardiopulmonary pathophysiology, making it the correct disorder the nurse would recognize as the likely cause of cor pulmonale.
Choice D reason: Renal failure causes fluid overload but not cor pulmonale, which is specific to lung-related right heart strain. COPD is the cause, making this incorrect, as it doesn’t match the nurse’s understanding of cor pulmonale’s pulmonary origin.
Correct Answer is ["B","E"]
Explanation
Choice A reason: Urinary catheters manage incontinence but aren’t specific to status epilepticus, which risks seizures and hypoxia. Side rail pads prevent injury, making this incorrect, as it’s not a priority compared to the nurse’s focus on seizure-related equipment needs.
Choice B reason: Side rail pads protect the patient from injury during seizures, a common risk post-status epilepticus. This aligns with seizure safety protocols, making it a correct piece of equipment the nurse would have available in the patient’s room.
Choice C reason: Tongue blades are outdated and unsafe for seizures, risking oral injury. Oxygen masks address hypoxia, making this incorrect, as it’s not recommended compared to the nurse’s priority equipment for post-status epilepticus care and safety.
Choice D reason: Nasogastric suction is irrelevant for status epilepticus unless aspiration occurs, which isn’t assumed here. Side rail pads are key, making this incorrect, as it’s not a priority compared to the nurse’s seizure-focused equipment preparation.
Choice E reason: An oxygen mask ensures oxygenation if seizures recur, causing hypoxia post-status epilepticus. This aligns with respiratory support needs, making it a correct piece of equipment the nurse would have ready in the patient’s assigned room.
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