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?
Wear clothing with zippers instead of buttons.
Place locks at the tops of exterior doors.
Replace the carpet with hardwood floors.
Encourage physical activity prior to bedtime.
The Correct Answer is B
Choice A rationale:
Wearing clothing with zippers instead of buttons does not address the safety concerns related to Alzheimer's disease. This choice does not ensure the client's safety or prevent wandering, which are common issues in Alzheimer's patients.
Choice B rationale:
Placing locks at the tops of exterior doors is essential for the safety of clients with Alzheimer's disease. Alzheimer's patients often have a tendency to wander and may become disoriented, putting them at risk of getting lost or injured outside the home. Proper locks can prevent them from leaving the house unsupervised.
Choice C rationale:
Replacing the carpet with hardwood floors may reduce the risk of falls but does not specifically address the safety concerns related to Alzheimer's disease. It is important to focus on measures that prevent wandering and ensure the client's safety in various situations.
Choice D rationale:
Encouraging physical activity prior to bedtime is a good practice for promoting sleep in older adults but does not directly address the safety concerns of Alzheimer's patients. Safety measures, such as securing doors, supervising the client, and preventing wandering, are more crucial in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Acupuncture is typically administered by a trained acupuncturist, not by the nurse. It is not commonly initiated upon arrival at the labor unit.
Choice B rationale: Biofeedback is a technique that usually requires prior training and practice; it is not typically taught for the first time at the beginning of labor.
Choice C rationale: Transcutaneous electrical nerve stimulation (TENS) can help manage back pain during labor but is not specifically used for pelvic pressure.
Choice D rationale: Using an ultrasound picture as a focal point during contractions is a common nonpharmacological pain management technique. Focal points help the client concentrate and manage pain through visualization and distraction.
Correct Answer is A
Explanation
Choice A rationale:
Spotting is a common finding in placenta previa. It occurs due to the abnormal implantation of the placenta over or near the cervical os, leading to vaginal bleeding. This bleeding can range from mild spotting to severe hemorrhage and is a significant sign of placenta previa.
Choice B rationale:
Nausea is not a specific sign of placenta previa. Nausea and vomiting are common symptoms during early pregnancy but are not directly related to placenta previa.
Choice C rationale:
A board-like abdomen is a sign of peritonitis or an acute abdomen, which is not associated with placenta previa. This finding suggests intra-abdominal inflammation and is unrelated to the condition in question.
Choice D rationale:
Delayed menses is a common sign of pregnancy, but it does not specifically indicate placenta previa. Placenta previa is characterized by vaginal bleeding, which is not synonymous with a delay in menstrual periods.
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