A client diagnosed with moderate Alzheimer's has been admitted to a long-term care facility. Which of the following are appropriate activities for the nurse to include in the care plan?
Drawing with crayons
Dangling ribbons or a mobile
Listening to music, watching TV, or videos
Board games
The Correct Answer is C
Choice A Reason: This is incorrect because drawing with crayons may be too childish or frustrating for a client with moderate Alzheimer's. Crayons may also pose a choking hazard or cause messes. The nurse should provide activities that are suitable for the client's cognitive and functional level, as well as their interests and preferences.
Choice B Reason: This is incorrect because dangling ribbons or a mobile may be too stimulating or confusing for a client with moderate Alzheimer's. These items may also trigger agitation or wandering behaviors. The nurse should provide activities that are calming and familiar for the client.
Choice C Reason: This is correct because listening to music, watching TV, or videos can be enjoyable and beneficial for a client with moderate Alzheimer's. Music can evoke memories, emotions, and positive responses. TV or videos can provide entertainment, education, and socialization. The nurse should choose music, TV shows, or videos that are appropriate and meaningful for the client.
Choice D Reason: This is incorrect because board games may be too complex or challenging for a client with moderate Alzheimer's. Board games may require memory, concentration, logic, or strategy skills that the client may have lost. The nurse should provide activities that are simple and easy for the client to follow.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is incorrect because a drop in heart rate from 74 to 68/min is not a manifestation that requires immediate reporting to the provider. A mild decrease in heart rate can be normal or due to other factors such as medication, sleep, or relaxation. It does not indicate a worsening of brain injury or increased intracranial pressure.
Choice B reason: This is the correct answer because a change in the Glasgow Coma Scale score from 14 to 10 is a manifestation that requires immediate reporting to the provider. The Glasgow Coma Scale is a tool that measures the level of consciousness based on eye-opening, verbal response, and motor responses. A score of 14 indicates mild impairment, while a score of 10 indicates moderate impairment. A decrease in score can indicate deterioration of neurological status and increased intracranial pressure, which can be life-threatening.
Choice C reason: This is incorrect because the headache is not a manifestation that requires immediate reporting to
the provider. Headache is a common symptom of mild TBI and can be managed with analgesics, rest, and hydration. It does not indicate a worsening of brain injury or increased intracranial pressure unless it is severe, persistent, or accompanied by other signs such as vomiting, confusion, or seizures.
Choice D reason: This is incorrect because diplopia is not a manifestation that requires immediate reporting to
the provider. Diplopia means double vision and can be caused by damage to cranial nerves or eye muscles due to TBI. It can be treated with eye patches, glasses, or surgery. It does not indicate a worsening of brain injury or increased intracranial pressure unless it is associated with other symptoms such as blurred vision, loss of vision, or eye pain.
Correct Answer is C
Explanation
Choice A Reason: Inserting a nasal swab to observe the fluid is contraindicated, as it can introduce infection or increase intracranial pressure. The fluid can be tested for glucose or halo sign to confirm cerebrospinal fluid (CSF) leakage.
Choice B Reason: Suctioning the nose gently with a bulb syringe is also contraindicated, as it can create negative pressure and increase CSF leakage or cause meningitis.
Choice C Reason: This is the correct answer because allowing the drainage to drip onto a sterile gauze pad can prevent contamination and facilitate observation of the amount and characteristics of the fluid.
Choice D Reason: Inserting sterile packing into the nares is not recommended, as it can obstruct the drainage and increase intracranial pressure or infection risk.
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