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 C
Explanation
Rationale:
A. Instruct the client to be NPO for six hours prior to the procedure: Amniocentesis is typically done under local anesthesia and does not require sedation or general anesthesia, so there is no need for the client to be NPO beforehand.
B. Instruct the client to maintain a full bladder for the procedure: A full bladder is required during early pregnancy to help lift the uterus for better visualization. However, at 22 weeks gestation, the uterus is already an abdominal organ, and a full bladder is not necessary.
C. Monitor the fetal heart rate prior to the procedure: Monitoring the fetal heart rate before an amniocentesis is essential to establish a baseline and ensure fetal well-being. It also aids in identifying any immediate changes following the procedure.
D. Place the client in Trendelenburg position during the procedure: The Trendelenburg position is not appropriate for amniocentesis. The client is typically placed in a supine or slightly tilted position to allow proper access to the uterus and avoid vena cava compression.
Correct Answer is B
Explanation
Rationale:
A. Limit your fluid intake to 500 milliliters per day: Restricting fluids to this extent can lead to dehydration and concentrated urine, which may irritate the bladder and worsen incontinence symptoms. Maintaining adequate hydration is essential during bladder retraining.
B. Plan to urinate every 3 hours while you are awake: Scheduled voiding every 2 to 3 hours helps train the bladder to hold urine for longer intervals and reduces urgency episodes. This is a core component of effective bladder retraining for urge incontinence.
C. Decrease your intake of cranberry juice: Cranberry juice may help prevent urinary tract infections, though its benefit in incontinence management is limited. There is no need to avoid it unless advised for another reason, as it is not a known bladder irritant.
D. Take your diuretic medication with your evening meal: Taking diuretics late in the day increases nighttime urine production, leading to nocturia and disturbed sleep. Diuretics should be taken in the morning to align with daytime urinary patterns and reduce bladder strain at night.
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