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 B
Explanation
A. "Your heart condition is caused by excessive stretching of the ventricles": This statement is incorrect. Excessive stretching of the ventricles typically occurs in dilated cardiomyopathy, not restrictive cardiomyopathy (RCM). In RCM, the primary issue is not excessive stretching but rather stiffening of the ventricular walls.
B. "Your heart condition is caused from stiffening of the walls of the ventricles": This statement is correct. Restrictive cardiomyopathy (RCM) is characterized by abnormal stiffening (fibrosis) of the ventricular walls, which impairs the heart's ability to fill properly during the diastolic phase of the cardiac cycle. This stiffening restricts the heart's ability to relax and fill with blood efficiently.
C. "Your heart condition is caused by thickening of the ventricular walls and septum": This statement describes hypertrophic cardiomyopathy (HCM), not restrictive cardiomyopathy (RCM). In HCM, there is abnormal thickening of the ventricular walls and septum, leading to impaired filling of the ventricles and potential obstruction of blood flow out of the heart.
D. "Your heart condition is caused when the ventricular tissue becomes fibrous and fatty": This statement describes arrhythmogenic right ventricular cardiomyopathy (ARVC), not restrictive cardiomyopathy (RCM). ARVC is characterized by replacement of myocardial tissue with fibrous and fatty tissue, primarily affecting the right ventricle.
Correct Answer is A
Explanation
Tonometer intraocular pressure reading 8 mm Hg (Option A): A low intraocular pressure reading may indicate a detached retina. In a detached retina, the vitreous humor (gel-like substance in the eye) may leak into the space behind the retina, causing a decrease in intraocular pressure. However, it's important to note that intraocular pressure alone cannot definitively diagnose a detached retina, and further diagnostic tests, such as a dilated eye examination or retinal imaging, would be needed for confirmation.
Smooth retina edges identified on slit-lamp biomicroscope examination (Option B): In the case of a detached retina, the edges of the retina may appear irregular or undulating rather than smooth. This irregularity is often observed during a dilated eye examination rather than with a slit-lamp biomicroscope.
Visual acuity of 20/20 using the Snellen eye chart (Option C): Visual acuity may be affected in a detached retina, depending on the extent and location of the detachment. However, visual acuity alone cannot confirm a detached retina, as other factors such as refractive errors or cataracts can also affect visual acuity.
Lens and cornea appear intact during ophthalmoscope exam (Option D): While a detached retina may be visualized during an ophthalmoscope examination as a gray or whitish area behind the lens, the appearance of the lens and cornea being intact does not definitively diagnose a detached retina. A thorough dilated eye examination by an ophthalmologist is necessary for accurate diagnosis.
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