A nurse is contributing to the plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Encourage socialization as a distractor when the client becomes agitated.

Limit instructions to two steps at a time.

Vary the staff providing care for the client

Encourage independence in ADLs.

Answer and Explanation

The Correct Answer is B

A. "Encourage socialization as a distractor when the client becomes agitated.": Socialization might exacerbate agitation; calm environments and redirection are better strategies.
B. "Limit instructions to two steps at a time.": Simplified instructions accommodate the cognitive limitations of Alzheimer’s clients, reducing confusion and frustration.
C. "Vary the staff providing care for the client.": Consistent caregivers are essential for maintaining familiarity and reducing anxiety in clients with Alzheimer's disease.
D. "Encourage independence in ADLs.": Independence should only be encouraged as much as the client can manage safely; overemphasis might lead to frustration or harm.

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Correct Answer is B

Explanation

A. "Prefers not to look at the stoma site.": Avoidance suggests denial or difficulty accepting the body change.
B. "Participates in performing ostomy care." Active participation in care indicates the client is adjusting to their new body image and accepting their altered appearance.
C. "Denies feelings of sadness about the ostomy.": Denial of emotions does not necessarily mean acceptance. Acknowledging and expressing feelings is important for adjustment.
D. "Accepts that sexual activity will decrease.": This statement reflects resignation rather than acceptance. Many clients with a colostomy maintain an active sexual life.

A. Trendelenburg with legs extended B. Supine with knees flexed C. Semi-Fowler's with legs extended D. Left-lateral with knees flexed

Correct Answer is B

Explanation

A. "Trendelenburg with legs extended.": Trendelenburg increases pressure on the abdomen, worsening evisceration.
B. "Supine with knees flexed.": This position reduces abdominal tension, minimizing further protrusion of the contents and providing comfort until surgical intervention.
C. "Semi-Fowler's with legs extended.": This position does not adequately reduce abdominal tension.
D. "Left-lateral with knees flexed.": Lateral positions are not suitable because they do not address abdominal tension or allow easy surgical access.

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A nurse is contributing to the plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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