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 B

Explanation

Choice A reason: Applying soft restraints to all extremities is not appropriate during a seizure as it can increase the risk of injury. The priority is to ensure the client's safety by preventing injury without restraining them.

Choice B reason: Removing objects that could cause injury is crucial. During a seizure, the client may move unpredictably, and any nearby objects could pose a risk of harm. Clearing the area ensures the client has a safe space to have the seizure without additional hazards.

Choice C reason: Placing pillows around the client's head can provide some protection, but it is not as immediately effective or necessary as removing potentially harmful objects from the surrounding area. Ensuring a clear and safe environment is the primary concern.

Choice D reason: Administering oxygen per nasal cannula is not the first priority during a seizure. While maintaining oxygenation is important, the immediate focus should be on ensuring the client's physical safety by removing dangerous objects. Once the seizure subsides, appropriate respiratory support can be provided if needed.

A. Determine if the client has a sliding scale insulin prescription. B. Stop the infusion until the healthcare provider is notified. C. Assess the client's urinary output for the previous 24 hours. D. Review the client's record for a history of diabetes mellitus.

Correct Answer is A

Explanation

Choice A reason: Determining if the client has a sliding scale insulin prescription is crucial. A sliding scale insulin regimen can help manage elevated blood glucose levels effectively. In the case of a capillary glucose of 365 mg/dL, prompt intervention is needed to prevent hyperglycaemia-related complications, and insulin administration is the most appropriate immediate action.

Choice B reason: Stopping the infusion until the healthcare provider is notified may not be the best immediate action. While it is essential to address the hyperglycaemia, halting the parenteral nutrition infusion can affect the client's overall nutritional and fluid balance. The focus should be on managing the glucose levels promptly.

Choice C reason: Assessing the client's urinary output for the previous 24 hours is important for monitoring overall fluid status and kidney function, but it does not directly address the immediate need to manage the elevated glucose levels.

Choice D reason: Reviewing the client's record for a history of diabetes mellitus can provide valuable information for long-term management and understanding the client's baseline glucose control. However, it is not the most urgent action in response to an acutely elevated capillary glucose level. Immediate intervention with insulin is needed to address the hyperglycaemia.

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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

After placing a client who is having a seizure in the side-lying position, which intervention should the nurse implement?

Correct Answer is B

Explanation

The practical nurse (PN) reports to the charge nurse that a client who is receiving a parenteral nutrition infusion has a capillary glucose of 365 mg/dL (20.3 mmol/L). Which action should the charge nurse implement?

Correct Answer is A

Explanation

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