A nurse is caring for a client who has Alzheimer's disease and is confused. Which of the following actions should the nurse take?

Keep the television on at all times.

Hang abstract pictures on the walls.

Keep familiar personal items in the client's room.

Encourage bright lighting in the room.

Answer and Explanation

The Correct Answer is C

Choice A reason: Keeping the television on at all times can contribute to overstimulation and confusion for clients with Alzheimer's disease. It is better to have the television on at specific times and choose calming, familiar programs.

Choice B reason: Hanging abstract pictures on the walls can be confusing and disorienting for clients with Alzheimer's disease. Simple, familiar images or family photographs are more helpful in creating a comforting environment.

Choice C reason: The correct answer is c because keeping familiar personal items in the client's room can provide a sense of security and comfort. Familiar objects can help reduce confusion and anxiety in clients with Alzheimer's disease.

Choice D reason: While adequate lighting is important, bright lighting can sometimes cause discomfort or glare. It is better to have soft, consistent lighting that helps the client feel safe and oriented without causing overstimulation.

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Correct Answer is ["B","C","D","E"]

Explanation

Choice A reason: Adding the amount of bladder irrigation to the total output is incorrect. Instead, the nurse should subtract the amount of irrigation solution instilled from the total output to accurately measure the client's urine output.

Choice B reason: The correct answer is b because using sterile technique when preparing the irrigation solution is crucial to prevent introducing infections into the bladder or urinary tract during the continuous bladder irrigation process.

Choice C reason: The correct answer is c because ensuring the drainage tubing is patent and without obstruction is essential to maintain effective bladder irrigation and prevent complications such as bladder distention and clot formation.

Choice D reason: The correct answer is d because if the client reports a continual need to void, it may indicate that the irrigation is not functioning properly, and the surgeon should be contacted to assess the situation and make necessary adjustments.

Choice E reason: The correct answer is e because bright red urine or the presence of large clots can indicate active bleeding, which requires prompt notification of the surgeon for further evaluation and intervention.

A. A client who has uncontrolled hypertension B. A client who has chronic atrial fibrillation C. A client who has thrombocytopenia D. A client who has an arteriovenous malformation

Correct Answer is B

Explanation

Choice A reason: Uncontrolled hypertension is a significant risk factor for hemorrhagic stroke rather than ischemic embolic stroke. Hypertension can lead to the rupture of blood vessels in the brain, causing bleeding.

Choice B reason: The correct answer is b because chronic atrial fibrillation increases the risk of embolic stroke. In atrial fibrillation, the irregular heartbeat can lead to the formation of blood clots in the atria. These clots can travel to the brain and cause an ischemic stroke by blocking blood flow.

Choice C reason: Thrombocytopenia, characterized by low platelet count, primarily affects clotting and bleeding tendencies rather than directly increasing the risk of embolic stroke. It can, however, complicate the management of stroke due to bleeding risks.

Choice D reason: An arteriovenous malformation (AVM) is a tangle of abnormal blood vessels connecting arteries and veins in the brain. While AVMs can increase the risk of hemorrhagic stroke, they are not typically associated with ischemic embolic stroke.

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A nurse is caring for a client who has Alzheimer's disease and is confused. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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