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.

Make a schedule of daily tasks.

Ask questions that require more than one answer.

Have several family members visit daily.

Answer and Explanation

The Correct Answer is B

Explanation

B. Make a schedule for daily task.

Creating a schedule of daily tasks can provide structure and routine for individuals with Alzheimer's disease. This helps reduce confusion and frustration by providing a sense of familiarity and predictability. The schedule should be displayed in a visible location and include activities such as meals, personal care, medication administration, and any recreational or therapeutic activities. Following the schedule can help the client feel more oriented and decrease their frustration levels.

Limiting the use of familiar objects in (option A) should not be included because it may further increase frustration and disorientation. Familiar objects can provide comfort and a sense of security for individuals with Alzheimer's disease.

Asking questions that require more than one answer in (option C) should not be included because it can be overwhelming and confusing for someone with Alzheimer's disease. It is best to ask simple, straightforward questions to facilitate communication and comprehension.

Having several family members visit daily in (option D) should not be included because it may cause agitation and overstimulation for the client. It is important to maintain a calm and predictable environment, limiting the number of visitors and ensuring they are familiar to the client.
Therefore, the most appropriate intervention for the nurse to include is making a schedule of daily tasks (option B).

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Correct Answer is ["C"]

Explanation

A: The tubing should not be coiled on the bed, especially not above the collection bag, as this can interfere with the drainage of urine and increase the risk of infection.

B: The drainage bag should always be kept below the level of the bladder during ambulation to prevent backflow and reduce the risk of infection.

C: Securing the catheter tubing to the lower abdomen (for male clients) or thigh (for female clients) helps to reduce the risk of catheter displacement and trauma. Proper securing also prevents unnecessary tension on the tubing, which can cause urethral irritation.

D:A sterile specimen should be collected from the sampling port of the catheter tubing, not directly from the drainage bag, which could lead to contamination.

A. Ensure the device is kept below the level of the client's chest. B. Clamp the chest tube every 4 hr. C. Place the client in a supine position. D. Empty the collection chamber every 8 hr.

Correct Answer is A

Explanation

Ensuring the device is kept below the level of the client's chest is important to ensure that the drainage system functions properly by allowing the fluid and air to flow downhill. Placing the device below the level of the chest helps facilitate gravity drainage.

Continuous suction is required for proper functioning of the chest tube drainage system. Clamping the chest tube can disrupt the suction and impede the removal of air or fluid from the pleural space. Only in specific circumstances, such as when changing the drainage system or assessing for air leaks, may the healthcare provider request a temporary clamping of the chest tube.

Positioning the client semi-Fowler's, with the head of the bed elevated, can help promote lung expansion and improve oxygenation. The specific positioning may vary depending on the client's condition and the healthcare provider's recommendations.

The nurse should empty the collection chamber as per the facility's protocol, which typically includes monitoring the drainage and emptying it when it reaches a certain level. Regular emptying of the collection chamber helps maintain proper functioning of the chest tube system and allows for accurate measurement of drainage output.

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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

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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?