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 D
Explanation
A. Belching: A common, benign post-procedure occurrence.
B. Sore throat: Expected due to endoscope insertion.
C. Flatulence: Typically benign and not concerning post-EGD.
D. Abdominal pain: May indicate a perforation or other serious complication and requires immediate evaluation.
Correct Answer is []
Explanation
Potential condition: Deep vein thrombosis
Based on the provided information, the client is most likely experiencing Deep Vein Thrombosis (DVT). This is suggested by the client's history of smoking, lack of exercise, obesity, recent surgery, and the fact that they are not wearing sequential compression devices due to discomfort.
Actions to Take
- Request a prescription for a lower-extremity Doppler flow study: This will help confirm the presence of a blood clot in the deep veins.
- Assess for Homan's sign: This is a clinical test used to check for DVT, although it's not always reliable.
Parameters to Monitor
- Signs of bleeding after anticoagulation initiation: This is crucial because anticoagulants are often used to treat DVT, and monitoring for bleeding is essential.
- PT/INR and platelet count: These parameters help assess the effectiveness and safety of anticoagulation therapy.
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