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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a.This requires intervention because creases in the stockings can create pressure points that may lead to skin irritation or impaired circulation. The stockings should be applied smoothly and evenly to ensure proper compression and to avoid skin complications.
b.This is not necessary and can actually be incorrect. Antiembolic stockings should be applied with the correct side facing the client's skin. Turning them inside out could alter their effectiveness in providing the required compression.
c.This is appropriate. Applying antiembolic stockings before the client gets out of bed is recommended because it helps to promote venous return and prevent blood clots, especially if the client is immobile or has limited mobility.
d.This is appropriate. Asking the client to point their toes helps to ensure that the stockings can be applied correctly and fit well, reducing the risk of creating pressure points or causing discomfort.
Correct Answer is C
Explanation
Informed consent is a legal and ethical requirement for certain medical procedures. It involves providing the client with clear and comprehensive information about the procedure, including its risks, benefits, alternatives, and expected outcomes. The client must understand the information provided and voluntarily give their consent before the procedure can be performed.
Placement of a central venous catheter is an invasive procedure that carries risks and potential complications, making it necessary to obtain informed consent from the client.
Wound irrigation with an antibiotic solution is a standard nursing intervention for wound care and does not usually involve invasive procedures. Informed consent is not typically required for this procedure.
The administration of an iron injection using the Z-track technique is a standard nursing procedure. While it involves an injection, it is not typically considered an invasive procedure that would require informed consent.
Insertion of a nasogastric tube is a common procedure that involves passing a tube through the nose and into the stomach for various purposes, such as feeding, decompression, or medication administration. While it is an invasive procedure, it is often performed in emergency or critical care situations where the client's immediate well-being takes precedence. Informed consent may not be feasible or necessary in these situations, depending on the context and urgency.
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