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 {"A":{"answers":"A"},"B":{"answers":"B,C"},"C":{"answers":"B,C"},"D":{"answers":"B,C"},"E":{"answers":"B,C"},"F":{"answers":"A"}}

Explanation

Condition	Definition	Causes	Symptoms	Treatment
Agranulocytosis	A severe and potentially life-threatening reduction in the number of white blood cells (neutrophils) that fight infection.	Can be caused by some antipsychotic medications, such as clozapine, olanzapine, and quetiapine.	Sore throat, fever, chills, mouth ulcers, infections, bleeding, and fatigue.	Discontinuation of the offending medication, antibiotics, antifungals, and granulocyte colony-stimulating factor (G-CSF) injections to stimulate the bone marrow to produce more white blood cells.
Neuroleptic Malignant Syndrome (NMS)	A rare but serious reaction to antipsychotic medications, especially the older ones, such as haloperidol, fluphenazine, and chlorpromazine.	Can be triggered by high doses, rapid dose changes, or switching of antipsychotic medications.	High fever, muscle rigidity, altered mental status, autonomic instability (blood pressure changes, tachycardia, sweating, etc.), and elevated creatine kinase levels.	Discontinuation of the offending medication, supportive care, cooling measures, hydration, and medications such as dantrolene, bromocriptine, or amantadine to counteract the effects of dopamine blockade.
Serotonin Syndrome	A potentially life-threatening condition caused by excessive levels of serotonin in the brain.	Can be caused by taking too much of a serotonin-enhancing medication, such as selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), or other drugs that affect serotonin levels, such as tramadol, linezolid, or St. John’s wort. Can also be caused by combining two or more serotonin-enhancing medications.	Agitation, confusion, disorientation, anxiety, hallucinations, muscle spasms, tremors, shivering, hyperreflexia, incoordination, diarrhea, nausea, vomiting, blood pressure changes, tachycardia, and hyperthermia.	Discontinuation of the offending medication(s), supportive care, hydration, and medications such as benzodiazepines, cyproheptadine, or serotonin antagonists to reduce serotonin levels.

A. The client has developed difficulty ambulating. B. The client's next dressing change is scheduled in 4 hr. C. The client has state-sponsored health insurance. D. The client's vital signs are checked every 8 hr.

Correct Answer is A

Explanation

Choice A rationale:

In an interprofessional team meeting for a client, it is essential to include information about changes in the client's condition or any new developments that may impact their care. The statement that "The client has developed difficulty ambulating" is relevant as it indicates a change in the client's mobility status and may require additional interventions or assessments.

Choice B rationale:

The timing of the client's next dressing change (scheduled in 4 hr) is important information but may not be the highest priority to discuss in an interprofessional team meeting. It is more pertinent to focus on the client's current condition and any changes that have occurred.

Choice C rationale:

The client's health insurance status (state-sponsored health insurance) is not typically a central topic of discussion in an interprofessional team meeting unless it directly affects the client's care plan or access to specific treatments.

Choice D rationale:

The frequency of the client's vital sign checks (every 8 hr) is important information for the healthcare team to be aware of, but it may not be the most critical piece of information to include in the interprofessional team meeting. Changes in vital signs or trends would be more relevant to discuss.

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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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Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B,C"},"C":{"answers":"B,C"},"D":{"answers":"B,C"},"E":{"answers":"B,C"},"F":{"answers":"A"}}

Explanation

A nurse is participating in an interprofessional team meeting for a client.Which of the following information about the client should the nurse include?

Correct Answer is A

Explanation

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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?