A nurse is reinforcing teaching with the caregiver of a client who has Alzheimer's disease.
The caregiver reports that the client awakens at night and wanders.
Which of the following strategies should the nurse suggest?.
Use light restraints while the client is in bed.
Place a lock at the top of doors leading outside.
Encourage the client to nap during the day.
Administer an antianxiety medication before bedtime.
The Correct Answer is B
Choice A rationale:
Using restraints can lead to injury and is generally a last resort.
Choice B rationale:
Placing a lock at the top of doors can prevent the client from wandering outside and getting lost or injured.
Choice C rationale:
Encouraging napping during the day can actually disrupt the client’s sleep cycle and increase nighttime wakefulness.
Choice D rationale:
While medication can be helpful, non-pharmacological interventions should be tried first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
This statement indicates a delusion, not a command hallucination. Delusions are fixed false beliefs that are not based in reality.
Choice B rationale:
This statement indicates a command hallucination. Command hallucinations involve hearing voices that direct the person to take action.
Choice C rationale:
This statement indicates paranoia, not a command hallucination. Paranoia involves intense anxious or fearful feelings and thoughts often related to persecution or threat.
Choice D rationale:
This statement indicates a visual hallucination, not a command hallucination. Visual hallucinations involve seeing things that aren’t there.
Correct Answer is C
Explanation
Choice A rationale:
Restricting interactions with other clients may be necessary in some cases, but it’s not the first precaution to take. The nurse must first ensure the client’s safety.
Choice B rationale:
Documenting the client’s behavior every 2 hr is important, but it’s not the first precaution. The nurse must first ensure the client’s safety.
Choice C rationale:
Implementing 24-hr one-to-one nursing observation is the first precaution the nurse should take. This ensures the client’s safety following an overdose.
Choice D rationale:
Administering prescribed medication via the IM route is not a precaution. It’s a method of medication administration.
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