A nurse is collecting data from the caregiver of a client who has Alzheimer's disease. The caregiver reports the client has difficulty sleeping at night and wanders throughout the house.
Which of the following interventions should the nurse recommend?
Give the client a barbiturate medication at bedtime.
Encourage the client to take frequent walks during the day.
Allow the client to nap for at least 1 hr during the day.
Put a simple lock on the client's bedroom door.
The Correct Answer is B
As a nurse, the intervention that should be recommended is encouraging the client to take frequent walks during the day. This will help the client expend some energy and reduce the restlessness that could be causing the sleep disturbance at night.
The other options are not recommended because barbiturate medications can cause excessive sedation, allowing the client to nap for at least 1 hour during the day can interfere with their ability to sleep at night, and putting a lock on the client's door can be a safety risk in case of an emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A.Using hydrogen peroxide for wound cleaning is not recommended as it can cause tissue damage and delay healing.
B.Burn dressings should typically be changed more frequently, often at least once per day, depending on the type and severity of the burn and the type of dressing used.Delaying dressing changes could increase the risk of infection.
C.In wound care, the nurse should cleanse the least contaminated wounds first to prevent spreading microorganisms from more contaminated areas to cleaner areas. This reduces the risk of cross-contamination and infection. For burns, starting with the cleanest areas ensures a safer wound management process.
D.Applying dressings with sterile gloves is essential to maintain a sterile environment and reduce the risk of infection, especially in clients with burns who are at high risk for infection due to compromised skin integrity.
Correct Answer is A
Explanation
a. Sounds are high-pitched.
Hyperactive bowel sounds are bowel sounds that are louder and more frequent than normal. They may be heard as high-pitched rushing or tinkling sounds that occur irregularly at a rate greater than 5-6 sounds per minute. They are often associated with increased intestinal motility, such as in diarrhea, gastroenteritis, or early bowel obstruction.
Option b is incorrect because hyperactive bowel sounds are not typically associated with a paralytic ileus, which is a condition where the bowel stops working and there is a lack of bowel sounds.
Option c is incorrect because hyperactive bowel sounds indicate increased motility, not decreased motility.
Option d is incorrect because soft bowel sounds at a rate of 1/min are considered hypoactive bowel sounds, which can be a sign of decreased intestinal motility, as seen in constipation or postoperative ileus.
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