In planning care for a client with early stage Alzheimer's disease, the nurse establishes the nursing problem of risk for injury related to impaired judgment. Which intervention is most important for the nurse to include in this client's plan of care?

Engage the client in regularly scheduled activities during the day.

Offer the client frequent reassurance that he/she will be safe.

Arrange the client's environment so the client can move about freely.

Assign a UAP to provide the client with total personal care.

Answer and Explanation

The Correct Answer is C

Clients with early-stage Alzheimer's disease may experience impaired judgment and cognitive decline, which can increase their risk for injury. Arranging the client's environment in a way that allows them to move about freely helps promote their safety and reduces the risk of accidents or falls.

Engaging the client in regularly scheduled activities during the day is a beneficial intervention as it provides structure and stimulation for the client. However, it may not directly address the risk for injury related to impaired judgment.

Offering the client frequent reassurance that they will be safe is important to provide emotional support, but it may not be sufficient in preventing physical harm or addressing the specific nursing problem of risk for injury.

Assigning a UAP (Unlicensed Assistive Personnel) to provide the client with total personal care may be helpful in assisting with activities of daily living. However, it does not directly address the risk for injury related to impaired judgment, and the nurse should have a central role in coordinating and overseeing the client's care.

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Correct Answer is C

Explanation

In this scenario, the client's sudden onset of feeling apprehensive, restlessness, and increased body temperature are consistent with symptoms of a thyroid crisis, also known as thyroid storm or thyrotoxic crisis. Thyroid crisis is a life-threatening condition that requires immediate medical intervention.

Initiating IV access is crucial to ensure the prompt administration of medications and fluids to manage the thyroid crisis effectively. IV access allows for the administration of beta-blockers, antithyroid drugs, and supportive care, which are essential components of the treatment for thyroid crisis. IV access also provides a route for fluid resuscitation if necessary.

Accessing laboratory results to confirm a thyroid crisis is important, but the clinical presentation of the client with sudden onset symptoms and a known history of uncontrolled hyperthyroidism suggests the need for immediate intervention rather than waiting for laboratory confirmation.

Obtaining a complete set of vital signs is an important assessment to gather comprehensive data, but in the case of a suspected thyroid crisis, immediate intervention takes precedence over obtaining vital signs.

Encouraging relaxation and slow deep breathing may be beneficial in managing anxiety or discomfort, but it does not address the underlying emergency situation of a thyroid crisis. The nurse should focus on initiating appropriate medical interventions first.

A. Encourage the use of ice on the areola. B. Teach about the use of a breast pump. C. Offer supplemental formula feedings. D. Recommend using a breast shield. E. None F. None

Correct Answer is D

Explanation

Choice A rationale: Applying ice can cause vasoconstriction and potentially inhibit the let-down reflex. While it might temporarily firm the tissue, it does not effectively address the anatomical challenge of inverted nipples.

Choice B rationale: While a pump can help draw out a nipple or maintain supply, the immediate concern is the baby's inability to latch at the breast for a successful feeding session.

Choice C rationale: Offering formula as a first-line intervention can undermine the mother's breastfeeding goals and interfere with the establishment of her milk supply and the infant's natural sucking reflex.

Choice D rationale: A breast shield is a silicone device that fits over the nipple and areola, providing a firm, protruded surface for the infant to latch onto when nipples are flat.

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In planning care for a client with early stage Alzheimer's disease, the nurse establishes the nursing problem of risk for injury related to impaired judgment. Which intervention is most important for the nurse to include in this client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The nurse determines that the client's nipples are inverted. Which action should the nurse implement?

Correct Answer is D

Explanation

A client with unilateral hearing loss is admitted for a scheduled surgery. Which technique should the nurse use to provide education about pain relief options?

The healthcare provider prescribes dopamine 2 mcg/kg/min intravenously (IV) for client who weighs 60 kg. The IV bag contains dopamine 200 mg in dextrose 5% in water (DW) 250 mL. The nurse should program the infusion pump to deliver how many mL/hour? (Enter numerical value only.)

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client Indicates that the teaching was effective?

An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first?

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome Indicates that the program was effective?

When assessing a newborn girl with salt-wasting congenital adrenal hyperplasia due to 21 hydroxylase deficiency, the nurse notes that the infant has an enlarged clitoris. Which intervention should the nurse implement?