A nurse is caring for a client who has Alzheimer's disease and is going to transition from home to a skilled nursing facility. Which of the following interventions should the nurse incorporate into the plan of care to help the client with this transition and avoid relocation stress syndrome?
Leave the client alone while ensuring safety, to allow the client to work through behaviors and feelings during the transition period.
Provide opportunities for education and continually evaluate the client's preferences and goals for care.
Limit the members of the team who can help the client while transitioning, to avoid adding confusion or uneasiness.
Inform the client about the need to move prior to the actual event.
The Correct Answer is B
B. Provide opportunities for education and continually evaluate the client's preferences and goals for care:
This is the most effective intervention. Providing education and involving the client (to the extent possible) in decision-making helps reduce anxiety and build trust. Even though individuals with Alzheimer's disease may have limited memory and cognitive abilities, ongoing communication about the transition and individualized care plans can help ease the process. Additionally, continuously evaluating the client's preferences and goals ensures that the care plan remains person-centered and aligns with their needs, helping to minimize relocation stress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. White blood cell level of 5,900 mm3: While abnormal white blood cell levels can indicate infection or inflammation, they are not typically associated with directly contributing to an episode of delirium. However, underlying conditions that cause abnormal white blood cell levels, such as infection or inflammation, may contribute to delirium.
B. Potassium level of 4.1 mEq/L: Potassium imbalances can lead to various neurological symptoms, including weakness, paralysis, and cardiac arrhythmias. However, a potassium level of 4.1 mEq/L is within the normal range and is unlikely to directly contribute to an episode of delirium.
C. Hemoglobin level of 14.2 g/dL: Hemoglobin levels reflect the oxygen-carrying capacity of the blood and are not directly associated with delirium. While severe anemia or hypoxia can cause neurological symptoms, a hemoglobin level of 14.2 g/dL is within the normal range and is unlikely to directly contribute to delirium.
D. Blood glucose level of 254 mg/dL: Elevated blood glucose levels, as indicated by a blood glucose level of 254 mg/dL, can contribute to an episode of delirium. Hyperglycemia can lead to alterations in cerebral metabolism, neuronal dysfunction, and impaired cognitive function, predisposing individuals to delirium. Additionally, hyperglycemia can exacerbate preexisting neurological conditions and increase the risk of developing delirium in critically ill patients. Therefore, monitoring and managing blood glucose levels are essential in preventing and managing delirium in hospitalized patients.
Correct Answer is B
Explanation
A. "Vision changes occur when the retina begins to breakdown and collect bits of debris": This statement does not accurately describe the changes that occur in the eye during retinal detachment. Vision changes in retinal detachment primarily occur due to the separation of the retina from its underlying tissue layers, rather than the breakdown and collection of debris within the retina.
B. "Vision changes occur when retinal tissue pulls away from the blood vessels in the eye": Retinal detachment occurs when the retina, which is the light-sensitive layer at the back of the eye, pulls away from its normal position along the inner wall of the eye. This separation disrupts the blood supply to the retina, leading to vision changes. The most common symptom of retinal detachment is the sudden appearance of floaters or flashes of light in the visual field, followed by a shadow or curtain effect as the detachment progresses. Therefore, this statement accurately describes the pathophysiological mechanism underlying vision changes in retinal detachment.
C. "Vision changes occur when the cloudy lens alters the passage of light through the eye": This statement describes changes associated with cataracts, not retinal detachment. Cataracts involve clouding of the lens inside the eye, which can lead to vision changes such as blurriness or decreased visual acuity. However, cataracts are distinct from retinal detachment, which involves the separation of the retina from the inner wall of the eye.
D. "Vision changes occur suddenly due to complete obstruction of aqueous humor outflow": This statement describes the pathophysiology of acute angle-closure glaucoma, not retinal detachment. Acute angle-closure glaucoma is characterized by sudden elevation of intraocular pressure due to complete obstruction of the outflow of aqueous humor, leading to rapid onset of symptoms such as severe eye pain, blurred vision, and halos around lights. Retinal detachment, on the other hand, is characterized by the separation of the retina from its normal position, resulting in distinct vision changes such as floaters, flashes of light, and visual field defects.
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