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 ["A","B","D"]
Explanation
Choice A Rationale: A weakened gag reflex is a potential complication of a cervical spinal cord injury and can lead to difficulties in swallowing and increased risk of aspiration.
Choice B Rationale: Hyperthermia can occur as a result of autonomic dysfunction associated with spinal cord injuries, especially when the injury is at a high cervical level.
Choice C Rationale: Absence of bowel sounds is not typically associated with cervical spinal cord injuries but may be seen in lower spinal cord injuries.
Choice D Rationale: Hypotension is a potential complication due to impaired autonomic regulation in cervical spinal cord injuries.
Choice E Rationale: Polyuria is not typically associated with cervical spinal cord injuries but may occur in cases of lower spinal cord injuries affecting bladder function.
Correct Answer is C
Explanation
Choice A Rationale: Educating about the importance of proper food handling is important for preventing foodborne illnesses but is not specific to the care of a client with tetanus.
Choice B Rationale: Offering food at least 4 times a day may be necessary for maintaining nutritional support, but it does not address the specific care needs of a client with tetanus.
Choice C Rationale: Anticipating administration of opioids is an important component of the care plan for tetanus. Opioids can help manage muscle spasms and severe pain associated with tetanus.
Choice D Rationale: Providing distraction activities may be beneficial for clients with tetanus to help divert their attention from muscle spasms and discomfort, but it is not the primary intervention.
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