A nurse in a long-term care unit is assisting in the care of a client who has Alzheimer's disease. Which of the following actions should the nurse take?
Participate in reminiscence therapy with the client.
Raise the four side rails on the client's bed.
Alternate the client's daily routine.
Keep the lights dimmed.
The Correct Answer is A
The correct answer is choice A, participate in reminiscence therapy with the client. This is an effective intervention for individuals with Alzheimer's disease. It involves encouraging the client to discuss past experiences and events. It has been shown to improve mood, decrease agitation, and increase communication skills. The reminiscence therapy should be individualized and tailored to the client's interests and abilities.
- Raising the four side rails on the client's bed is not the correct answer because this could cause harm to the client by restricting their mobility and independence.
- Alternating the client's daily routine is not the correct answer because individuals with Alzheimer's disease benefit from a consistent routine, which helps them to feel more secure and less anxious.
- Keeping the lights dimmed is not the correct answer because it can be disorienting and confusing for clients with Alzheimer's disease, who need adequate lighting to distinguish their surroundings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice a. "You will be moderately sedated during the procedure."
Choice A rationale: Colonoscopy is a common procedure used for both diagnostic and therapeutic purposes in gastroenterology. Moderate sedation, also known as conscious sedation, is typically administered to patients undergoing colonoscopy to ensure their comfort and cooperation during the procedure. This level of sedation allows the patient to maintain their protective reflexes and respond to verbal commands, while also reducing anxiety and discomfort. The sedative agents commonly used for colonoscopy include benzodiazepines such as midazolam and analgesics such as fentanyl. The nurse should emphasize the use of moderate sedation to the patient, reassuring them that they will be in a relaxed state throughout the procedure without compromising their safety.
Choice B rationale: The statement suggesting that the patient will lie on their right side for the procedure is incorrect. During a colonoscopy, patients are typically positioned on their left side with their knees drawn up towards their chest. This left lateral decubitus position facilitates the advancement of the colonoscope through the colon and provides better visualization for the healthcare provider performing the procedure. Placing the patient on the right side would not provide optimal positioning and may hinder the progress of the colonoscopy.
Choice C rationale: The information provided in statement c. is incorrect regarding the dietary restrictions before a colonoscopy. Prior to the procedure, patients are instructed to follow a clear liquid diet for 24 to 48 hours, depending on the healthcare provider's instructions. Clear liquids include water, clear broth, tea, coffee without milk or cream, strained fruit juices (such as apple or white grape juice), and sports drinks. Solid foods, as well as liquids that are not transparent, should be avoided during this preparatory period to ensure adequate bowel cleansing and visualization during the colonoscopy.
Choice D rationale: The recommendation to warm the liquid bowel preparation before consumption, as stated in option d., is incorrect. Bowel preparations typically consist of polyethylene glycol-based solutions, which are intended to be consumed at room temperature or chilled. Warming the solution could alter its composition and taste, potentially causing discomfort or nausea in the patient. It is essential for patients to follow the specific instructions provided by their healthcare provider or the product labeling regarding the administration of bowel preparation to ensure effective bowel cleansing before the colonoscopy.
Choice E rationale: Repeated for emphasis, the advice to warm the liquid bowel preparation before consumption is incorrect and redundant. Patients should adhere strictly to the instructions provided by their healthcare provider or the product labeling regarding the administration of bowel preparation. Warming the solution is not recommended and could compromise the effectiveness of the preparation, leading to suboptimal bowel cleansing and potentially impacting the accuracy of the colonoscopy results.
Correct Answer is ["D","E"]
Explanation
Running cool water over the affected area will help to decrease pain and prevent further tissue damage. Allowing the affected area to remain open to air will help to promote healing and prevent infection.
A. "Apply ice to the larger blisters" is an incorrect answer because applying ice can cause further damage to the skin and delay healing.
B. "Administer ibuprofen for pain" is an incorrect answer because the nurse cannot administer medications without a physician's order.
C. "Maintain skin integrity over the blisters" is an incorrect answer because maintaining skin integrity over the blisters can cause further damage and delay healing.
Explanation: The nurse should run cool water over the affected area and allow it to remain open to the air to promote healing and prevent infection. Applying ice or medication without a physician's order can cause further damage and delay healing.
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