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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Rationale:

A. The client is tolerating clear liquids: After gastric banding, clients typically start with clear liquids within the first 24–48 hours. Tolerating clear liquids at 36 hours post-op is an expected and desired outcome that indicates gastrointestinal recovery and readiness to progress the diet gradually.

B. The client is voiding at least 250 mL/hr: This urine output is abnormally high and could indicate diuresis or overhydration. The expected minimum urine output is around 30 mL/hr, so this value exceeds normal expectations and is not typical postoperatively.

C. The client is maintaining bed rest: Early ambulation is encouraged after bariatric procedures to prevent complications such as deep vein thrombosis or pulmonary embolism. Prolonged bed rest is not expected or recommended.

D. The client is consuming 1,000 calories daily: At 36 hours post-op, clients are still on a very restricted intake—usually clear liquids or small sips—and would not be consuming 1,000 calories. This intake would be excessive and inappropriate at this stage of recovery.

A. Temperature 38.3° C(101° F) B. Heart rate 58/min C. Blood pressure 146/96 mm Hg D. Oxygen saturation 95% on 2 L nasal cannula E. DTR 2+ bilaterally F. Urine output 40mL in the last hour

Correct Answer is ["D","E","F"]

Explanation

Rationale for correct choices:

DTR 2+ bilaterally: This is within the normal range and shows recovery from previous central nervous system depression caused by magnesium sulfate toxicity, which earlier caused a drop to 1+.
Urine output 40 mL in the last hour: Output is improving from the prior 20 mL/hr, suggesting better renal perfusion and clearance of magnesium. Adequate urine output is critical to prevent accumulation and toxicity.
Oxygen saturation 95% on 2 L nasal cannula: This value meets the prescribed goal and reflects stabilized respiratory function after earlier shallow breathing. It indicates successful oxygenation support.

Rationale for incorrect choices:

Temperature 38.3° C (101° F): This is an elevated temperature and may indicate systemic infection or inflammation. It does not support an improvement in condition and warrants monitoring.
Heart rate 58/min: This is bradycardia and could indicate lingering effects of magnesium toxicity or a vagal response. It does not reflect improvement and needs further assessment.
Blood pressure 146/96 mm Hg: Although slightly lower than the earlier reading of 170/112 mm Hg, it is still in the hypertensive range and does not signify resolution of preeclampsia or stabilization.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is 36 hr postoperative following gastric banding. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

Correct Answer is ["D","E","F"]

Explanation

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