A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of the flu. During the night shift, the client is found climbing into the bed of another client who becomes upset and scared. Which of the following actions should the nurse take?
Assist the client to the correct room.
Medicate the patient with antipsychotics.
Move the client to a room at the end of the hall.
Place the client in restraints.
The Correct Answer is A
Choice A rationale:
The nurse should prioritize the safety and well-being of both clients involved. Assisting the client with late-stage Alzheimer's disease to the correct room is important to prevent any further confusion or distress. Alzheimer's disease often causes cognitive impairment, memory loss, and disorientation, which can lead to situations where the individual may not recognize their surroundings or the people around them. Guiding the client back to their own room will help reduce confusion, agitation, and potential conflicts with other clients.
Choice B rationale:
Medicating the patient with antipsychotics is not the most appropriate initial action in this situation. Antipsychotic medications are often used to manage severe behavioral disturbances associated with conditions like schizophrenia or dementia, but their use should be carefully considered due to potential side effects. In this scenario, addressing the immediate situation and guiding the client back to their room is more appropriate than resorting to medication.
Choice C rationale:
Moving the client to a room at the end of the hall is not the best choice because it doesn't directly address the current situation. While changing the client's room might be considered in some cases to reduce agitation or wandering, it's not the immediate action needed when the client is found in another client's bed. Guiding the client to the correct room is the priority.
Choice D rationale:
Placing the client in restraints is not an appropriate choice in this situation. Restraints should only be used as a last resort for ensuring the safety of the client or others when less restrictive interventions have failed. Placing a client with Alzheimer's disease in restraints can be traumatic and lead to increased agitation and psychological distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
"This is supposed to happen when you get old, right?" is a common misconception but doesn't necessarily support the diagnosis of delirium. It could be attributed to normal aging changes.
Choice B rationale:
"Since his mother died, he has not been feeling well." indicates a potential stressor but doesn't directly address the rapid onset of behavioral changes, which is a hallmark of delirium.
Choice C rationale:
"My husband just didn't seem to know what he was doing. He has been forgetful for years." suggests a history of forgetfulness rather than an acute change in behavior, which is more indicative of chronic cognitive issues like dementia.
Choice D rationale:
(Correct) "The changes in his behavior came on so quickly! I wasn't sure what was happening." This statement supports the diagnosis of delirium, which is characterized by a sudden onset of confusion and changes in cognitive function. Delirium often develops rapidly, and the client's wife's observation aligns with this diagnostic criterion.
Correct Answer is C
Explanation
Choice A rationale:
The Brief Patient Health naire (Brief PHQ) is primarily used for assessing the presence and severity of depressive symptoms and not specifically for cognitive disorders. It consists of nine items that assess the frequency of specific symptoms over the past two weeks.
Choice B rationale:
The Scale for Assessment of Negative Symptoms (SANS) is a tool used to assess negative symptoms in schizophrenia and other related psychotic disorders. It includes items related to affective blunting, alogia, anhedonia, and avolition, which are not directly relevant to the assessment of cognitive disorders.
Choice C rationale:
The Mental Status Examination (MSE) is a comprehensive assessment of cognitive function, including orientation, memory, attention, language, and executive function. It provides valuable information about the client's cognitive abilities and can aid in diagnosing cognitive disorders such as dementia or delirium.
Choice D rationale:
The Abnormal Involuntary Movements Scale (AIMS) is used to assess the presence and severity of tardive dyskinesia, a movement disorder commonly associated with the use of antipsychotic medications. It is not relevant to the assessment of cognitive disorders.
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