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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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Completing hourly endotracheal suctioning: Hourly endotracheal suctioning is not typically indicated for a client with increased intracranial pressure (ICP). Frequent suctioning can lead to increased intrathoracic pressure and potentially compromise venous return, which may further elevate ICP. Suctioning should be performed as needed to maintain airway patency while minimizing the risk of increasing ICP.

B. Ensuring proper ventriculostomy transducer levels: Ensuring proper ventriculostomy transducer levels is important for accurate measurement of intracranial pressure (ICP) but may not directly alleviate elevated ICP. Monitoring ICP through ventriculostomy allows for timely detection of changes in ICP, which can guide interventions to manage elevated pressure levels. However, it is not a direct intervention to reduce ICP.

C. Monitoring volume status: Monitoring volume status is important in managing a client with increased intracranial pressure (ICP) as both hypovolemia and hypervolemia can impact ICP. However, monitoring volume status alone does not directly address elevated ICP. Interventions to optimize volume status, such as fluid administration or diuresis, may be implemented based on assessment findings, but they should be done cautiously to avoid exacerbating cerebral edema or altering cerebral perfusion.

D. Elevating the head of the bed 15°: Elevating the head of the bed 15° (or higher) is a crucial intervention for managing a client with increased intracranial pressure (ICP). This position helps promote venous drainage from the brain, reducing venous congestion and intracranial pressure. Elevating the head of the bed also helps prevent cerebrospinal fluid (CSF) from pooling in the brain, which can further increase ICP. Placing the client in a semi-upright position is a standard practice in managing ICP and is recommended in various clinical guidelines.

A. "Since my parent suffered from Alzheimer's disease, I know that I am at an increased risk for developing the disease myself." B. "The cause of Alzheimer's disease is still not fully known or understood." C. "l do not have to worry about this because I do not have Down syndrome and I have never had a stroke." D. "My child is at risk for developing Alzheimer's disease because they have trisomy 21."

Correct Answer is C

Explanation

A. "Since my parent suffered from Alzheimer's disease, I know that I am at an increased risk for developing the disease myself." This statement is accurate. Family history is a significant risk factor for Alzheimer's disease. Individuals with a first-degree relative (such as a parent or sibling) with Alzheimer's disease are at a higher risk of developing the condition themselves.

B. "The cause of Alzheimer's disease is still not fully known or understood." This statement is also accurate. While there are theories about the underlying causes of Alzheimer's disease, such as genetics, brain changes, and environmental factors, the exact cause is still not fully understood. Research into the etiology of Alzheimer's disease is ongoing.

C. "I do not have to worry about this because I do not have Down syndrome and I have never had a stroke." This statement indicates a need for further teaching. While it is true that individuals with Down syndrome and those who have had a stroke are at increased risk for developing Alzheimer's disease, they are not the only populations at risk. Alzheimer's disease can affect individuals without Down syndrome or a history of stroke. Other risk factors include age, family history, genetics, and lifestyle factors.

D. "My child is at risk for developing Alzheimer's disease because they have trisomy 21." This statement is accurate. Trisomy 21, also known as Down syndrome, is associated with an increased risk of developing Alzheimer's disease. Individuals with Down syndrome have three copies of chromosome 21, which contains the gene for amyloid precursor protein (APP). Overproduction of amyloid beta protein, derived from APP, is thought to contribute to the development of Alzheimer's disease in individuals with Down syndrome.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse plan to include in the plan of care?

Correct Answer is D

Explanation

A nurse is teaching clients at a senior center about the etiology of Alzheimer's disease. Which of the following statements by a client indicates the need for further teaching?

Correct Answer is C

Explanation

A nurse is planning care for a client who has hypertrophic cardiomyopathy that has not improved after pharmacologic treatment. Which of the following procedures should the nurse anticipate the health care provider ordering?

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