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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Peer-reviewed journal articles undergo a rigorous review process by experts in the field before being published. This process ensures that the information presented is based on sound research methods, accurate data, and relevant evidence. Journal articles are considered reliable sources of information as they are reviewed by experts in the field, and the research findings can contribute to evidence-based practice.

First-hand experience with wound care products: While personal experience can be valuable, it may not always reflect the most up-to-date or evidence-based practices. Individual experiences can be subjective and may not have been subject to rigorous evaluation or research.

Information from a wound care product vendor: Information from a vendor may be biased and focused on promoting their own products. It is important to critically evaluate the information and consider whether it is supported by evidence and aligns with current best practices.

An entry on a nursing blog addressing wound healing: Blog entries can vary in quality and credibility. Not all blogs are written or reviewed by experts, and the information provided may not always be evidence-based or reliable. It is important to critically assess the source, author's qualifications, and references cited in the blog post.

A. Elevated blood pressure. B. Clammy skin. C. Fruity breath odor. D. Bounding pulse.

Correct Answer is C

Explanation

Choice A rationale:

Elevated blood pressure is not typically associated with diabetic ketoacidosis (DKA) In fact, individuals with DKA often experience low blood pressure due to dehydration.

Choice B rationale:

Clammy skin can occur in DKA due to dehydration and metabolic disturbances, but it is not a specific finding that differentiates DKA from other conditions.

Choice D rationale:

A bounding pulse is not a characteristic finding in DKA. Individuals with DKA may have a rapid pulse due to the stress on the body, but it is not typically described as bounding.

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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?

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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?