A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
Encourage physical activity prior to bedtime
Wear clothing with zippers instead of buttons.
Replace the carpet with hardwood floors
Place locks at the tops of exterior doors.
The Correct Answer is D
Rationale:
A. Encourage physical activity prior to bedtime: Stimulating activity close to bedtime can increase agitation and make it harder for clients with Alzheimer’s disease to settle for sleep. Calming routines in the evening are more appropriate to reduce nighttime confusion and restlessness.
B. Wear clothing with zippers instead of buttons: Although zippers are often easier than buttons, clients with Alzheimer’s may have difficulty with any fasteners. Simple clothing with Velcro or elastic waists is typically more suitable to promote independence.
C. Replace the carpet with hardwood floors: Carpets provide traction and cushioning, which can help prevent injuries from falls. Hardwood floors may be slippery or cause confusion due to glare or unfamiliar patterns, increasing fall risk.
D. Place locks at the tops of exterior doors: Clients with Alzheimer’s are at risk for wandering. Installing locks at the tops of doors—out of the client's usual line of sight—helps prevent elopement while preserving safety in the home environment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Rationale:
A. Sleep pattern: Two days without sleep is a red flag in bipolar disorder and may lead to worsening mania or psychosis. Addressing sleep deprivation is a priority to reduce the risk of exhaustion or psychotic deterioration.
B. Skin turgor: Poor skin turgor suggests dehydration, which may be due to poor fluid intake or prolonged activity. It requires immediate follow-up to prevent complications like electrolyte imbalances or renal injury.
C. Hallucinations: Persistent visual hallucinations may indicate an acute psychotic episode or manic psychosis. These require immediate psychiatric intervention to ensure client safety and stabilization.
D. Heart rate: A heart rate of 120/min indicates tachycardia, possibly related to dehydration, agitation, or underlying mania. It requires prompt evaluation to rule out cardiovascular strain or systemic causes.
E. Hygiene: While poor hygiene is a concern and can indicate mental health deterioration, it is not immediately life-threatening. It can be addressed after acute issues such as dehydration, tachycardia, and psychosis are managed.
Correct Answer is D
Explanation
Rationale:
A. Ham sandwich with milk: Ham is pork, which is strictly prohibited under kosher dietary laws. Additionally, meat and dairy cannot be consumed together in a kosher meal, making this choice doubly inappropriate for someone following kosher rules.
B. Shrimp salad and tomato soup with milk: Shellfish, including shrimp, are non-kosher because they lack fins and scales. Combining shrimp (non-kosher seafood) with dairy also violates kosher dietary principles, making this an unsuitable option.
C. Bacon and cheese quiche with milk: Bacon is pork and non-kosher, and mixing it with cheese violates the rule against combining meat and dairy. Even if the bacon were turkey-based, kosher observance would still require strict supervision and certification.
D. Scrambled eggs and toast with milk: Eggs, bread, and milk are all permissible under kosher law if prepared in accordance with kosher standards. This option avoids mixing meat and dairy and excludes non-kosher animals, making it suitable for a kosher diet.
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