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":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A,B"}}
Explanation
Rationale:
- Excessive spending habits: This behavior is hallmark for mania, where impaired judgment, impulsivity, and inflated self-esteem lead to reckless financial decisions.
- Hallucinations: Hallucinations, especially visual or auditory ones, are classic signs of psychosis. They indicate a break from reality and are not a diagnostic feature of mania alone unless psychotic features are present.
- Pressured speech: Pressured, rapid, and loud speech is a diagnostic feature of mania, reflecting heightened psychomotor activity and racing thoughts.
- Lack of sleep: Insomnia without fatigue is typical in mania. Clients may stay awake for days with increased energy levels and no perceived need for rest.
- Disorganized thought process: This can appear in both mania and psychosis. In mania, it stems from flight of ideas and distractibility. In psychosis, it results from impaired reality testing and cognitive disintegration.
Correct Answer is C
Explanation
Rationale:
A. Maintain bed elevation at 20°: To reduce the risk of aspiration, the head of the bed should be elevated to at least 30°–45° during and after enteral feedings. A 20° elevation is insufficient to prevent gastric reflux and aspiration.
B. Check for gastric residual every 12 hr: Gastric residuals should generally be checked every 4–6 hours for clients receiving continuous enteral feedings. Waiting 12 hours increases the risk of feeding intolerance or aspiration from undetected residual accumulation.
C. Flush the tubing with 30 mL of water every 4 hr: Routine flushing helps prevent tube occlusion and maintains patency. It also ensures that the client receives adequate hydration, especially with continuous feeding systems.
D. Place enough formula in the container to last 18 hr: Formula in an open system should not hang longer than 4 hours due to the risk of bacterial contamination. Adding 18 hours’ worth increases the chance of microbial growth and infection.
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