The nurse is caring for an older adult client with Alzheimer's disease who becomes increasingly agitated and is speaking to someone who is not visible to the nurse. Which action should the nurse implement?

Reduce the client's interaction with others during the day.

Awaken the client for reality checks every 4 hours at night.

Clarify reality with the client about delusional thoughts.

Use distraction and therapeutic communication skills.

Answer and Explanation

The Correct Answer is D

Choice A reason: Reducing the client's interaction with others during the day can potentially isolate the client and exacerbate feelings of agitation and confusion. Social interaction is important for cognitive stimulation and emotional well-being, even for clients with Alzheimer's disease.

Choice B reason: Awaking the client for reality checks every 4 hours at night can disrupt the client's sleep pattern, leading to increased agitation and confusion. Proper rest is crucial for clients with Alzheimer's disease to help manage their symptoms effectively.

Choice C reason: Clarifying reality with the client about delusional thoughts can sometimes increase agitation if not done sensitively. Clients with Alzheimer's disease may not respond well to direct confrontation about their delusions. It is often more effective to use techniques that do not directly challenge their perception of reality.

Choice D reason: Using distraction and therapeutic communication skills is the best approach. This strategy helps redirect the client's attention to a different, more calming activity, which can reduce agitation. Therapeutic communication involves understanding and validating the client's feelings while gently guiding them towards a more positive state. This approach respects the client's experience and provides support without escalating their agitation.

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Correct Answer is C

Explanation

Choice A reason: Obtaining a fingerstick glucose every 6 hours is important for monitoring blood glucose levels and ensuring they are within the target range. However, it is not the most critical intervention for preventing diabetic ketoacidosis. Testing for ketones provides more specific information on the development of DKA.

Choice B reason: Ensuring IV fluids are infusing continuously is crucial for maintaining hydration and preventing electrolyte imbalances, particularly in a client who may be at risk for DKA. However, this intervention is supportive and not as directly related to detecting the onset of DKA as testing for ketones.

Choice C reason: Testing urine for the presence of ketones is the most important intervention. The presence of ketones indicates that the body is breaking down fat for energy instead of using glucose, which is a hallmark of diabetic ketoacidosis. Early detection of ketones allows for prompt intervention to prevent the progression of DKA.

Choice D reason: Teaching the client how to manage sick days is essential for long-term diabetes management and preventing complications during illness. However, for the immediate prevention of DKA in the hospital setting, testing for ketones is more urgent and directly related to detecting and managing the condition.

A. Tell the client to lay on the left side to prevent the tongue from falling back into the mouth. B. Teach the client to take medication an hour before meals to enhance the swallowing reflex. C. Prepare the client and family for the future need of a gastrostomy tube for feeding. D. Encourage the client and family to provide a semi-solid diet with thick liquids.

Correct Answer is D

Explanation

Choice A reason: Telling the client to lay on the left side to prevent the tongue from falling back into the mouth is not a standard intervention for managing swallowing difficulties in Parkinson's disease. The focus should be on dietary modifications and safe swallowing techniques.

Choice B reason: Teaching the client to take medication an hour before meals to enhance the swallowing reflex is not a widely recognized intervention for managing swallowing difficulties. While timing of medication can be important, dietary adjustments are more immediately effective.

Choice C reason: Preparing the client and family for the future need of a gastrostomy tube for feeding might be necessary if swallowing difficulties progress significantly. However, it is not the first line of intervention and should be considered only after other measures have been tried.

Choice D reason: Encouraging the client and family to provide a semi-solid diet with thick liquids is the most appropriate intervention. Semi-solid and thickened liquids are easier to swallow and less likely to cause choking or aspiration, which is crucial for managing dysphagia in clients with Parkinson's disease.

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The nurse is caring for an older adult client with Alzheimer's disease who becomes increasingly agitated and is speaking to someone who is not visible to the nurse. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The home health nurse is caring for a client with Parkinson's disease who is beginning to experience swallowing difficulties. Which intervention should the nurse include in this client's plan of care?

Correct Answer is D

Explanation

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