During the evening shift, a client with Alzheimer's disease becomes agitated, restless, and repeatedly attempts to leave the room unattended. Which intervention should the nurse implement?

Take a walk with the client.

Sit the client in a recliner.

Administer a sleeping medication.

Move the client to a locked unit.

Answer and Explanation

The Correct Answer is A

Choice A reason: Taking a walk with the client is an effective intervention for addressing agitation and restlessness in a client with Alzheimer's disease. Physical activity can help reduce anxiety and agitation, and walking provides a safe and structured way for the client to expend energy while being closely supervised.

Choice B reason: Sitting the client in a recliner may provide temporary comfort, but it does not address the underlying agitation and restlessness. The client may still attempt to leave the room and become more frustrated if their movement is restricted.

Choice C reason: Administering a sleeping medication can have sedative effects, but it should not be the first-line intervention for agitation and restlessness in clients with Alzheimer's disease. Non-pharmacological approaches, such as walking, should be tried first. Sedatives can also increase the risk of falls and other complications.

Choice D reason: Moving the client to a locked unit may be necessary for safety in some cases, but it should not be the initial intervention for agitation and restlessness. The goal is to use less restrictive interventions first to manage the client's behaviour.

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Correct Answer is D

Explanation

Choice A reason: Serum potassium of 5.0 me/L and serum sodium of 138 me/L are within normal ranges and do not reflect the expected electrolyte imbalances due to dehydration from vomiting and diarrhea.

Choice B reason: Serum potassium of 4.5 me/L and serum sodium of 140 me/L are also within normal ranges. This does not reflect the typical imbalance caused by dehydration.

Choice C reason: Serum potassium of 3.5 me/L and serum sodium of 142 me/L are normal values. They do not indicate the electrolyte disturbances expected with dehydration from vomiting and diarrhea.

Choice D reason: Serum potassium of 3.0 me/L indicates hypokalaemia (low potassium), and serum sodium of 149 me/L indicates hypernatremia (high sodium). These imbalances are expected in a client with a history of fever, vomiting, and diarrhea, as these conditions can lead to loss of potassium and concentration of sodium due to dehydration.

A. Notify the charge nurse that the client will need assignment to the COVID-19 specified area of the facility. B. Place the nasal swab specimen for COVID-19 directly into a biohazard bag. C. Maintain a 6 feet (1.8 meters) distance from the client unless wearing an N95 respirator and personal protective equipment (PPE) for droplet precautions. D. Start an intravenous infusion for an antiviral drug to be administered for positive COVID-19 test results.

Correct Answer is C

Explanation

Choice A reason: Notifying the charge nurse that the client will need assignment to the COVID-19 specified area of the facility is an important action for infection control. However, the most immediate priority is to protect oneself and others by maintaining appropriate distance and using PPE.

Choice B reason: Placing the nasal swab specimen for COVID-19 directly into a biohazard bag is necessary for safe specimen handling and to prevent contamination. While important, it follows after ensuring that proper PPE is used and distancing measures are maintained.

Choice C reason: Maintaining a 6 feet (1.8 meters) distance from the client unless wearing an N95 respirator and personal protective equipment (PPE) for droplet precautions is the most crucial action. This step ensures the nurse’s safety and reduces the risk of virus transmission. Proper PPE and distancing protocols are essential in managing a suspected COVID-19 case.

Choice D reason: Starting an intravenous infusion for an antiviral drug to be administered for positive COVID-19 test results is part of the treatment plan if the test comes back positive. However, this step comes after ensuring safety through proper use of PPE and maintaining distance from the client.

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During the evening shift, a client with Alzheimer's disease becomes agitated, restless, and repeatedly attempts to leave the room unattended. Which intervention should the nurse implement?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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