A nurse in a provider's office is caring for a client.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

A. Keep the client's bedroom dark at night is not recommended. People with Alzheimer's disease may experience confusion and disorientation, especially during the night. Keeping the room well-lit can help reduce confusion and improve the client's sense of time.

B. Place a large-face clock in the client's bedroom is a helpful strategy. A large clock can help the client orient themselves to the time of day, which can reduce anxiety and confusion. This is an effective way to help clients with Alzheimer's disease maintain a sense of time and structure.

C. Cover electrical outlets in the client's home with tape is not a necessary safety measure for Alzheimer's disease. While safety is important, the primary focus should be on reducing the risk of falls, confusion, and disorientation. Tape on outlets is not a standard safety recommendation for Alzheimer's patients.

D. Hang a monthly calendar in the client's bedroom is a good idea for some clients, but a calendar may not be as immediately helpful as a clock in the bedroom. While a calendar can help orient the client to the date, a clock is more effective for helping them understand the time of day.

A. Encouraging the client to urinate every 2 hr is not appropriate in this situation because the client is receiving continuous bladder irrigation (CBI), and the urinary catheter is meant to drain continuously. The issue is likely related to a blockage or clot in the catheter, not the need for the client to urinate.

B. Securing the urinary catheter to the upper left quadrant is not appropriate because the catheter should be positioned properly to allow for proper drainage. Securing it in an inappropriate location could cause kinks or obstructions.

C. Using 0.9% sodium chloride to perform an intermittent bladder irrigation is the correct action. The client’s scant amount of fluid and bladder spasms suggest that the catheter may be blocked, likely by a clot. Performing an intermittent irrigation with saline can help clear any obstructions in the catheter and restore proper drainage.

D. Applying a cold compress to the suprapubic area is not appropriate for treating bladder spasms caused by a potential obstruction. The priority action is to clear the catheter and ensure proper drainage.