A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease.
The client becomes agitated and combative when the nurse approaches him.
Which of the following actions should the nurse plan to take?
Calmly ask the client if he would like to listen to some music.
Turn the water on and ask the client to test the temperature.
Firmly tell the client that good hygiene is important.
Obtain assistance to place mitten restraints on the client.
The Correct Answer is A
Choice A rationale:
It is essential for the nurse to employ non-pharmacological interventions to manage behavioral issues in clients with Alzheimer's disease. Offering to play music is a suitable approach to distract and soothe the agitated client. Music can have a calming effect and may help reduce anxiety and agitation in clients with dementia. It is a safe and non-invasive intervention that respects the client's autonomy and preferences.
Choice B rationale:
Turning the water on and asking the client to test the temperature (choice B) may not be an appropriate initial response. This action may increase the client's agitation as it involves immediate physical contact and may not address the underlying issue of the client's distress.
Choice C rationale:
Firmly telling the client that good hygiene is important (choice C) is not a recommended approach. Using a firm tone or being authoritative can escalate the client's agitation and may not effectively address the behavioral issue. It's important to use a calm and respectful approach when caring for clients with Alzheimer's disease.
Choice D rationale:
Obtaining assistance to place mitten restraints on the client (choice D) should not be the first choice. Restraints should only be used as a last resort when other methods have failed, and they should be used in accordance with institutional policies and guidelines. Restraints can have adverse physical and psychological effects and should be avoided whenever possible.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
"This medication can increase your risk for sunburn." Ciprofloxacin, a fluoroquinolone antibiotic, can increase the risk of sunburn and photosensitivity reactions. Patients taking this medication should be advised to use sunscreen, wear protective clothing, and avoid excessive sun exposure to prevent sunburn.
Choice B rationale:
"Take an antacid if the medication causes gastrointestinal upset." Ciprofloxacin should not be taken with antacids or other products containing calcium, magnesium, aluminum, or iron, as these can interfere with its absorption. Therefore, advising the patient to take an antacid with ciprofloxacin is incorrect.
Choice C rationale:
"Restrict your daily fluid intake while taking this medication." There is no need to restrict fluid intake while taking ciprofloxacin. In fact, it is important for patients to stay well-hydrated to prevent potential side effects like crystalluria. Adequate fluid intake helps dilute the urine and reduce the risk of crystal formation.
Choice D rationale:
"Expect to experience diarrhea while taking this medication." Diarrhea can be a side effect of ciprofloxacin, but it is not something patients should necessarily expect. While gastrointestinal upset is a known side effect, not everyone who takes the medication will experience diarrhea. Patients should be advised to report any severe or persistent diarrhea to their healthcare provider.
Correct Answer is B
Explanation
Choice A rationale:
Tingling of the scalp. Tingling of the scalp is not a common adverse reaction following electroconvulsive therapy (ECT) ECT primarily affects the brain and may result in memory-related side effects, but tingling of the scalp is not typically associated with this procedure.
Choice C rationale:
Voice alteration. Voice alteration is not a common adverse reaction to ECT. ECT is a procedure that involves inducing controlled seizures in the brain, and its primary effects are on cognitive and neurological function rather than the vocal cords or voice.
Choice D rationale:
Neck pain. Neck pain is not a common adverse reaction to ECT. This procedure primarily affects the brain and central nervous system, and neck pain is not typically associated with it.
Choice B rationale:
Temporary memory loss. Temporary memory loss is a well-documented and common adverse reaction to electroconvulsive therapy (ECT) ECT can affect memory consolidation, and clients may experience temporary memory gaps or difficulties recalling recent events. However, these memory deficits are usually short-term and improve over time.
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