A nurse is caring for a client who has Alzheimer's disease.
Which of the following findings should the nurse expect?

The correct answer is D.

Choice A reason: “A. Using this machine increases my risk of overdose.” This statement is incorrect because PCA pumps are designed with safety mechanisms to prevent overdose. The pump is programmed to deliver a specific dose of medication at set intervals, and it will not dispense more medication than what is prescribed by the healthcare provider.

Choice B reason: “B. I can get pain medication any time as long as I press the button.” While it is true that the patient can self-administer medication, PCA pumps have a lockout interval that prevents the machine from delivering another dose until a certain amount of time has passed, ensuring that the patient cannot receive medication too frequently.

Choice C reason: “C. My partner can press my pain medication button for me if I am sleeping.” This statement is incorrect. Only the patient should press the button on the PCA pump to ensure that the medication is administered safely and according to the patient’s current level of pain. Allowing someone else to press the button could lead to unsafe dosing.

Choice D reason: “D. I will receive a limited amount of pain medication when I press the button.” This is the correct statement. The PCA pump allows the patient to administer a controlled amount of pain medication within safe limits set by the healthcare provider. The pump is programmed to deliver a specific dose of medication, and there is a limit to the number of doses that can be administered per hour.

Choice A rationale:

Requesting a provider to evaluate the client in person every 36 hours might be necessary in certain situations but is not directly related to the management of a client in seclusion and restraints. It does not ensure the immediate safety and well-being of the client in this scenario.

Choice B rationale:

Documenting the client's behavior every 15 minutes is essential when a client is in seclusion and restraints. Regular and detailed documentation is crucial to monitor the client's response to the intervention, ensuring their safety, and providing necessary information for the healthcare team.

Choice C rationale:

Ensuring that the prescription for restraints be renewed every 6 hours is important to prevent unnecessary or prolonged use of restraints, but it doesn't address the immediate need for monitoring the client in seclusion and restraints.

Choice D rationale:

Monitoring the client every 30 minutes while restrained might not provide timely information, especially if the client's condition deteriorates rapidly. More frequent monitoring, such as every 15 minutes, allows for closer observation and quicker response to any changes in the client's status.