A home health nurse is caring for a client who has Alzheimer's disease. The client's son is concerned about his mother becoming frustrated. Which of the following interventions should the nurse include?

Limit the use of familiar objects.

Ask questions that require more than one answer.

Make a schedule of daily tasks.

Have several family members visit daily.

Answer and Explanation

The Correct Answer is C

Creating a schedule of daily tasks can help provide structure and routine for individuals with Alzheimer's disease. Having a predictable routine can reduce confusion and frustration by providing a sense of familiarity and stability. The schedule should include activities that the client enjoys and can manage within their abilities. It can help the client feel more organized and engaged throughout the day.

Limiting the use of familiar objects is not recommended. Familiar objects can provide comfort and a sense of security for individuals with Alzheimer's disease. They can help trigger memories and create a sense of familiarity in their environment. Removing familiar objects may increase disorientation and frustration.

Asking questions that require more than one answer can be overwhelming for individuals with Alzheimer's disease. Complex questions can lead to confusion and frustration as the person may struggle to recall or process information. It is best to ask simple and direct questions that can be easily understood and answered.

Having several family members visit daily may cause additional stress and confusion for the client with Alzheimer's disease. Too many visitors can be overwhelming and may disrupt the person's routine or environment. It is important to consider the individual's preferences and abilities when planning visits and ensure that they are manageable and supportive for the client's well-being.

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Correct Answer is B

Explanation

A. Incorrect. Mentioning the completion of an incident report is appropriate but not sufficient in explaining the incident.
B. Correct. Documenting the client's own statement about the fall is essential for accuracy and clarity in the medical record.
C. Incorrect. While footwear might contribute to falls, it's important to include the client's own account of the fall in the documentation.
D. Incorrect. While noting the absence of visible injuries is relevant, it's more important to document the circumstances leading to the fall.

A. Oxygen saturation B. Weight C. Heart rate D. Blood pressure E. Temperature F. Sputum characteristics G. Respiratory complaint H. Travel history

Correct Answer is ["B","E","F","G","H"]

Explanation

A. The oxygen saturation is within normal range hence no need to evaluate further
B. Weight: The client has reported a significant weight loss of 2.26 kg (5 lbs.) over the past week. Unintentional weight loss can be a concerning symptom and may require further assessment.
C. Heart rate: The client's heart rate is within range.
D. Blood pressure is within normal range
E. The temperature is slightly elevated and indicates a need for further evaluation.
F. Sputum characteristics: The client reports "blood-tinged sputum." Coughing up blood in the sputum, known as hemoptysis, is a potentially serious symptom that warrants further evaluation to determine its cause.
G. Respiratory complaint: The client presents with a 4-day history of cough, often productive, along with other respiratory symptoms such as fatigue, night sweats, and a low-grade fever. These respiratory complaints require further evaluation to identify the underlying cause.
H. Travel history: The client recently traveled to South Africa and stayed for 3 weeks.
Travel history is important in assessing potential exposure to infectious diseases or other environmental factors that could contribute to the client's symptoms.

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A home health nurse is caring for a client who has Alzheimer's disease. The client's son is concerned about his mother becoming frustrated. Which of the following interventions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

Correct Answer is B

Explanation

A nurse is assisting in the care of a client who presents to the emergency department. Exhibits A nurse is reviewing the client's medical record, which of the following findings indicates the need for further evaluation? Select all that apply.

Correct Answer is ["B","E","F","G","H"]

Explanation

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