A nurse is contributing to the plan of care for a client who has partial-thickness and full-thickness burns on their lower extremities. Which of the following interventions should the nurse recommend including in the plan of care?

A. Limit the number of choices for the client: Offering too many options can overwhelm a client with Alzheimer’s disease and increase confusion or agitation. Limiting choices helps the client make decisions more easily and promotes a sense of control.

B. Provide a stimulating environment for the client: Excessive stimulation can increase confusion, agitation, and anxiety in clients with Alzheimer’s disease. A calm, structured environment is more appropriate to support cognitive function and reduce behavioral disturbances.

C. Use written signs to assist the client with locating the bathroom: As Alzheimer’s progresses, clients often lose the ability to read or interpret written language (alexia). Using pictures or symbols (e.g., a picture of a toilet on the bathroom door) is much more effective than written words for assisting with navigation.

D. Use confrontation to manage the client's behavior: Confrontation can escalate agitation and aggression in clients with Alzheimer’s disease. Approaches should focus on redirection, reassurance, and validation rather than confrontation.

A. Witnessing the death of their parents and sibling: Experiencing such severe trauma places the client at high risk for post-traumatic stress disorder (PTSD) and complicated grief. Immediate follow-up is necessary to assess emotional safety and provide appropriate mental health interventions.

B. Attends school regularly: Regular school attendance is a positive sign of functioning and does not require immediate follow-up. It indicates that the client maintains some level of daily routine and social engagement.

C. Client experiences nightmares: Nightmares following trauma can indicate PTSD or acute stress reaction. These symptoms warrant prompt assessment and intervention to prevent worsening sleep disturbances, anxiety, or functional impairment.

D. Blood pressure 122/80 mm Hg: This is within normal limits for a 16-year-old and does not require immediate follow-up. It is not indicative of acute physical risk.

E. Heart rate 99/min: While slightly elevated, this heart rate is within a mild range of normal for adolescents under stress and does not require immediate follow-up unless accompanied by other acute symptoms.

F. Startles easily during thunderstorms: A mild startle response, especially with a prior fear of storms, is not an urgent concern. While it may relate to trauma, it is not immediately dangerous or requiring urgent follow-up.

G. Friend reporting client is not themselves: Changes in behavior observed by peers can indicate worsening mental health or risk of self-harm. Immediate follow-up is important to evaluate mood, coping, and safety.

H. Smoking marijuana to clear their mind: Self-medicating with substances is a significant safety concern, particularly in adolescents coping with trauma. Immediate follow-up is required to assess for substance use disorder and potential harm to mental and physical health.