The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which is the best action by the nurse?
A Keep window blinds open during the day
B Have the patient take a mid-morning nap.
C Provide hourly orientation to time and place.
D Move the patient to a quiet room in the afternoon.
The Correct Answer is A
Choice A Rationale: Keeping window blinds open during the day is a non pharmacological approach to help regulate the patient's circadian rhythm and may reduce the severity of sundowning, a common phenomenon in dementia.
Choice B Rationale: Having the patient take a mid-morning nap may disrupt the patient's sleep-wake cycle and worsen sundowning.
Choice C Rationale: Providing hourly orientation to time and place may be overwhelming for the patient and not necessarily effective in addressing sundowning.
Choice D Rationale: Moving the patient to a quiet room in the afternoon may not address the underlying issue of sundowning and may not be practical in a long-term care setting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Rationale: Stage 3 of Alzheimer's disease is characterized by increased memory deficits, but the behavior of filling in information with made-up stories is more commonly associated with the earlier stages.
Choice B Rationale: Stage 2 of Alzheimer's disease involves progressive cognitive decline but may not necessarily manifest with the specific behavior described.
Choice C Rationale: Stage 1 of Alzheimer's disease typically has mild cognitive changes, but the behavior mentioned is more indicative of the later stages.
Choice D Rationale: The early stage of Alzheimer's disease may involve the emergence of confabulation, where clients fill in gaps in memory with fabricated stories or information.
Correct Answer is A
Explanation
Choice A Rationale: Sitting the client at a 90-degree angle (upright position) helps prevent orthostatic hypotension and cardiovascular complications in clients with spinal cord injuries by improving venous return and cardiac output.
Choice B Rationale: Administering 2000 liters of fluid is an inappropriate intervention, and the volume mentioned is excessive.
Choice C Rationale: Applying compression socks may help prevent deep vein thrombosis (DVT) but does not address cardiovascular complications related to sitting position.
Choice D Rationale: Maintaining blood pressure exactly at 110/80 is not a feasible or appropriate intervention.
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