A home care nurse is caring for a client who has advanced multiple.

sclerosis.

Nurses' Notes.

2 weeks ago:Today: The client reports depression is increasing as they are unable to. participate in activities they once enjoyed because of the.

advancing multiple sclerosis.

Even getting up to the wheelchair.

is "just too much" for them.

The home health aide reported client will not permit turning. position changes.

The client states, "I can only get comfortable.

curled on my left side.

I'm not moving.". Vital Signs.

Today:Temperature 36.8° C (98.2° F). Heart rate 80/min.

Respiratory rate 20/min.

BP 116/76 mm Hg. Client Education.

1 week ago:Educated the client about the importance of getting out of bed.

changing positions in bed.

Client stated, ""l try.". Select the 5 complications the client is at risk for.

The correct answer is: b. A room containing personal belongings.

Choice A rationale: A room without a window may lead to disorientation and a lack of natural light, which can disrupt the client's circadian rhythm, contributing to sleep disturbances and mood alterations. Adequate exposure to natural light helps regulate the body's internal clock and promotes a sense of well-being. Furthermore, natural light exposure has been linked to improved cognitive function and mood stability in individuals with cognitive impairments. Therefore, choosing a room with a window is essential for optimizing the client's therapeutic environment.

Choice B rationale: A room containing personal belongings is crucial for creating a therapeutic environment for a cognitively impaired client. Familiar items provide a sense of security and continuity, reducing anxiety and agitation. These belongings serve as anchors to the client's past experiences and identity, facilitating reminiscence therapy and promoting emotional connection. By surrounding the client with familiar objects, the nurse fosters a sense of autonomy and self-expression, empowering the client to engage in meaningful activities and maintain a sense of personal agency.

Choice C rationale: While proximity to the nursing station may facilitate monitoring and prompt intervention in case of emergencies, a room adjacent to the nursing station can also expose the client to constant noise and disruptions. Excessive auditory stimuli can overwhelm a cognitively impaired individual, leading to sensory overload and exacerbating confusion and disorientation. Moreover, the lack of privacy in such a location may compromise the client's dignity and autonomy, hindering their ability to engage in personal activities and interactions. Therefore, placing the client in a quieter, more secluded environment away from the nursing station is preferable for promoting a therapeutic atmosphere conducive to rest and relaxation.

Choice D rationale: Dim lighting poses significant risks for cognitively impaired clients, as it impairs visual perception and increases the likelihood of accidents and falls. Inadequate lighting compromises safety by obscuring obstacles and hazards in the environment, heightening the risk of injuries and fractures. Additionally, dimly lit spaces can exacerbate feelings of fear and anxiety, particularly in individuals with cognitive impairments who may already experience sensory processing difficulties. Bright lighting, on the other hand, enhances visibility and spatial orientation, promoting independence and confidence in daily activities. Therefore, ensuring sufficient illumination in the client's room is essential for mitigating safety hazards and optimizing their overall well-being.

Choice A rationale:

Baked potato chips are a healthier alternative to regular potato chips because they contain less fat due to the baking process. However, they are still a processed snack and might not be the healthiest option, especially for a school-age group. The high sodium content in many baked chips is also a concern for cardiovascular health.

Choice B rationale:

A milkshake made with whole milk might provide essential nutrients like calcium and protein, but it is also high in calories and can be loaded with sugar, especially if additional sugars or syrups are added. Consuming sugary beverages in excess can contribute to weight gain and dental issues.

Choice C rationale:

"Air-popped popcorn." This is the correct answer. Air-popped popcorn is a healthy whole-grain snack option. It is low in calories, high in fiber, and can be a good source of antioxidants. It is important to note that while air-popped popcorn is healthy, adding excessive butter, salt, or sugar can diminish its nutritional value.

Choice D rationale:

Cheesecake is a rich, high-calorie dessert that is not considered a healthy snack option. It is high in saturated fats, sugars, and calories, making it an occasional treat rather than a suitable healthy snack choice for school-age children.