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 B

Explanation

Rationale:

A. Provide frequent stimulation for the newborn: Newborns with neonatal abstinence syndrome (NAS) are often hypersensitive to stimuli. Excessive stimulation can worsen symptoms such as tremors, irritability, and sleep disturbances.

B. Decrease the lighting levels in the nursery: Reducing environmental stimuli such as bright lights and loud noises helps soothe infants with NAS. A calm, low-stimulation setting promotes comfort and minimizes overstimulation.

C. Wrap the newborn loosely in a blanket: Tight swaddling not loose wrapping is recommended for NAS to provide a sense of security and decrease tremors and agitation. Loose wrapping can increase distress and reduce effectiveness.

D. Encourage frequent eye contact with the newborn during feedings: Direct eye contact can be overstimulating for infants experiencing NAS. Instead, feedings should be calm and gentle, with minimal stimulation to reduce stress and improve tolerance.

A. Insert the catheter until resistance is felt B. Withdraw the catheter 1 to 2 cm (0.4 to 0.8 inch) C. Rotate the catheter while suctioning D. Lubricate the catheter with sterile saline.

Correct Answer is D,A,B,C

Explanation

Rationale:

A. Insert the catheter until resistance is felt: The catheter should be gently advanced into the tracheostomy tube until resistance is met, which typically indicates reaching the carina.

B. Withdraw the catheter 1 to 2 cm (0.4 to 0.8 inch): Slight withdrawal prevents trauma to the carina and positions the catheter optimally for effective suctioning.

C. Rotate the catheter while suctioning: Rotating the catheter as suction is applied allows for even clearing of secretions along the tracheal walls and helps prevent localized tissue damage.

D. Lubricate the catheter with sterile saline: Lubrication ensures smooth insertion and reduces trauma to the tracheal mucosa. This is the first action after applying sterile gloves.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has a tracheostomy and requires suctioning. Identify the sequence of steps the nurse should follow after applying sterile gloves. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is D,A,B,C

Explanation

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