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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
Nurses' Notes
0900:
Client who is at 38 weeks of gestation presents to the antepartum unit with uterine contractions, dark red vaginal bleeding, and abdominal pain that started approximately 45 min prior to arrival. Rates abdominal pain a 7 on a scale of 0 to 10. Client reports, "My blood pressure has been high during the pregnancy."
Home Medications: prenatal multivitamin, methyldopa 250 mg PO twice daily Physical Exam:
General: tearful, anxious
Cardiovascular: S1, S2, no murmur
Respiratory: bilateral breath sounds clear
Abdomen: Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant
FHR: 116/min, minimal variability noted
Rationale:
Dark red vaginal bleeding: This could indicate a serious complication such as placental abruption, which can lead to fetal and maternal distress. Dark red bleeding is often associated with this condition and requires immediate follow-up to determine the source and to prevent further complications.
Uterine hypertonicity with a board-like abdomen: Uterine hypertonicity and a "board-like" abdomen may suggest uterine contractions that are intense or sustained, which could be associated with placental abruption or other serious obstetric complications. This finding needs follow-up to assess for uterine rupture, abruption, or other causes of uterine distress.
Pain score of 7/10: The client's moderate-to-severe pain (rated 7/10) requires follow-up to manage pain and evaluate for its cause. Pain related to placental abruption or other complications may be severe and should be managed appropriately.
FHR of 116/min with minimal variability: A fetal heart rate (FHR) of 116/min is within the normal range, but minimal variability could suggest fetal distress or compromise. Follow-up is needed to continuously monitor fetal well-being and assess for any changes in FHR patterns.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
Explanation
- Memantine: This medication is commonly used to treat cognitive symptoms associated with Alzheimer's disease and other forms of dementia, which can include memory loss, confusion, and difficulty with daily tasks.
- Cognitive changes: The client's symptoms of getting lost, difficulty speaking, and misplacing things suggest significant cognitive decline, which memantine can help manage.
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