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 B

Explanation

Choice A reason: Petechial haemorrhage under the client's eyes can be a sign of various conditions, including increased intrathoracic pressure from vomiting. However, it is not the most urgent finding in this scenario. The nurse should focus on the finding that indicates a potential life-threatening condition.

Choice B reason: Right lower abdomen rebound tenderness is a sign of peritonitis, which can be caused by appendicitis or other serious abdominal conditions. This is an urgent finding that requires immediate medical attention, as it indicates inflammation of the peritoneum and potential risk of perforation or severe infection.

Choice C reason: Severe headache with photosensitivity can be associated with conditions such as meningitis or migraines. While concerning, it does not take precedence over the abdominal signs that indicate a potentially life-threatening condition like peritonitis.

Choice D reason: Dark green coloured emesis can be indicative of bile or upper gastrointestinal content, which might be seen in conditions such as intestinal obstruction or vomiting. However, it is not as urgent as the finding of rebound tenderness, which suggests an acute and severe abdominal condition that needs immediate intervention.

A. Review the client's fluid intake prior to bedtime. B. Obtain a fingerstick blood glucose level. C. Collect a urine specimen for culture analysis. D. Palpate the bladder above the symphysis pubis.

Correct Answer is D

Explanation

Choice A reason: Reviewing the client's fluid intake prior to bedtime is important for managing nocturia, but it does not address the immediate concern of urinary retention and difficulty starting the urinary stream.

Choice B reason: Obtaining a fingerstick blood glucose level is relevant for diagnosing diabetes, which can cause increased urination. However, it does not directly address the current urinary symptoms.

Choice C reason: Collecting a urine specimen for culture analysis can help identify a urinary tract infection, but it does not provide immediate assessment information regarding the client's bladder status.

Choice D reason: Palpating the bladder above the symphysis pubis is the most immediate and relevant intervention. This assessment helps determine if the bladder is distended, indicating urinary retention, which is a common issue in older adult males and can cause the symptoms described.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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