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.
Replace the carpet with hardwood floors.
Wear clothing with zippers instead of buttons.
Place locks at the tops of exterior doors.
The Correct Answer is D
A. Physical activity should be scheduled earlier in the day to prevent overstimulation and promote restful sleep.
B. Hardwood floors increase the risk of falls; carpets provide better traction and cushioning.
C. Zippers can be difficult for clients with Alzheimer's; clothing with Velcro or simple fasteners is preferred.
D. Placing locks at the tops of doors reduces the risk of wandering, a common safety concern in clients with Alzheimer's.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"},"H":{"answers":"A"}}
Explanation
|
Intervention |
Anticipated |
Contraindicated |
|
Keep neonate prone |
✅ |
|
|
Administer total parenteral nutrition (TPN) |
✅ |
|
|
Encourage parent bonding |
✅ |
|
|
Obtain an arterial blood gas |
✅ |
|
|
Attach OG tube to low intermittent suction |
✅ |
|
|
Repeat abdominal x-ray every 24 hr |
✅ |
|
|
Obtain a CBC and blood culture |
✅ |
|
|
Administer IV antibiotics |
✅ |
Rationale:
Keep neonate prone: Contraindicated. Placing the neonate in a prone position may increase the risk of aspiration, especially in the context of respiratory distress or abdominal issues, so it is generally avoided unless clinically necessary in a controlled environment.
Administer total parenteral nutrition (TPN): Anticipated. TPN may be required if the neonate is unable to tolerate oral or enteral feeding due to gastrointestinal distress, as seen with abdominal distention and blood in stool.
Encourage parent bonding: Anticipated. Parent bonding is important for the emotional and developmental support of the neonate, even in critical care settings. However, it must be done in a manner that does not compromise the neonate’s health (e.g., ensuring sterile technique).
Obtain an arterial blood gas: Anticipated. Given the neonate's respiratory status and potential infection, obtaining an ABG is appropriate to assess acid-base balance and oxygenation status.
Attach OG tube to low intermittent suction: Anticipated. Suctioning through the OG tube may be necessary if the neonate has signs of gastrointestinal distress, such as abdominal distention, to remove excess gastric contents or air.
Repeat abdominal x-ray every 24 hr: Contraindicated. Repeating an x-ray every 24 hours may not be necessary unless there are significant changes in the neonate’s condition. Continuous monitoring with clinical assessments is typically prioritized.
Obtain a CBC and blood culture: Anticipated. Given the neonate's lethargy, hypotonia, and other concerning signs, a CBC and blood cultures are necessary to evaluate for infection, which is a common complication in critically ill neonates.
Administer IV antibiotics: Anticipated. Administration of IV antibiotics is essential, especially with signs of possible infection such as lethargy, distended abdomen, and blood in the stool, which may indicate sepsis or necrotizing enterocolitis.
Correct Answer is C
Explanation
A. Storing oxygen tanks under the bed is not safe due to limited ventilation and fire hazards.
B. The oxygen gauge should be checked daily, not weekly, to monitor levels.
C. The oxygen tank should be placed away from curtains or drapes to reduce the risk of fire.
D. The oxygen tank wrench should be readily accessible in case of emergencies.
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