A client diagnosed with Alzheimer's Disorder has impairments of memory and judgement and is incapable of performing activities of daily living. Which nursing intervention should take priority?

Assist the client with bathing and toileting.

Design a bulletin board to represent the current season.

Present evidence of objective reality to improve cognition.

Label the door to the client's room with name and number.

Answer and Explanation

The Correct Answer is A

a. Assist the client with bathing and toileting. This intervention addresses the client's immediate and essential needs. Ensuring basic hygiene and toileting are crucial for maintaining the client's health, dignity, and comfort. Assisting with activities of daily living (ADLs) is a priority for clients who are unable to perform these tasks independently.
b. Design a bulletin board to represent the current season. While this can help with orientation and provide a sense of time and place, it is not as critical as addressing the client's basic physical needs.
c. Present evidence of objective reality to improve cognition. Reality orientation can be beneficial, but it is not a priority intervention compared to meeting the client's immediate physical needs.
d. Label the door to the client's room with name and number. This helps with orientation and independence but is less critical than ensuring the client’s hygiene and toileting needs are met.

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Correct Answer is A

Explanation

a. "I can see that you are upset. Let's talk about ways to resolve this." This is correct because it validates the client's feelings, encourages problem-solving, and maintains the therapeutic milieu's principles of respect and support.
b. "I'll fix this right away. You need to calm down." This response does not encourage the client’s participation in resolving the issue and does not foster the therapeutic milieu's goal of client empowerment.
c. "Let's find a way to avoid this conflict in the future." While this promotes future problem-solving, it does not address the immediate concern or validate the client's current feelings.
d. "You should bring this up during group therapy later this week." This delays addressing the client's immediate concerns and might make the client feel unheard.

A. "I am less likely to get an infection while taking this medication." B. "Weight loss is a sign that my medication dose is too low." C. "I will contact my healthcare provider if I have difficulty urinating." D. "I will stop taking this medication once my hallucinations go away."

Correct Answer is C

Explanation

a. "I am less likely to get an infection while taking this medication." This statement is incorrect. Chlorpromazine can actually increase the risk of infection due to potential side effects like agranulocytosis (a drop in white blood cell count).
b. "Weight loss is a sign that my medication dose is too low." This statement is incorrect. Chlorpromazine typically causes weight gain rather than weight loss.
c. "I will contact my healthcare provider if I have difficulty urinating." This statement indicates an understanding of one of the potential side effects of chlorpromazine, which can cause urinary retention due to its anticholinergic properties.
d. "I will stop taking this medication once my hallucinations go away." This statement is incorrect. Discontinuing antipsychotic medication without a healthcare provider's guidance can lead to a relapse of symptoms.

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A client diagnosed with Alzheimer's Disorder has impairments of memory and judgement and is incapable of performing activities of daily living. Which nursing intervention should take priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with schizophrenia, on an inpatient unit, approaches a nurse, stating, "Someone took my dinner! People need to respect others, and you need to do something about this now!" Which response by the nurse is guided by the basic assumption of the therapeutic milieu?

Correct Answer is A

Explanation

A client with schizophrenia is receiving teaching from the nurse about their prescribed medication, Chlorpromazine. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

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