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 D
Explanation
The correct answer is Choice D: Obtain the client's weight.
Choice D rationale: Obtaining the client's weight is crucial in planning hemodialysis treatment, as it helps determine the amount of fluid that needs to be removed during the procedure. This information contributes to accurate calculation of the ultrafiltration rate, ensuring adequate fluid balance and preventing potential complications associated with fluid overload or excessive fluid removal.
Choice A rationale: Encouraging the client to increase fluid intake is not recommended in the context of hemodialysis, as excessive fluid intake may result in fluid overload, a common complication in patients undergoing this treatment. Instead, the nurse should advise the client on appropriate fluid restrictions, taking into account their individualized plan of care.
Choice B rationale: Reinforcing the practice of sleeping on the side of the access site is not advisable because it could lead to increased pressure on the arteriovenous fistula, potentially causing complications such as thrombosis or stenosis. It is generally recommended that clients avoid putting pressure on the access site, particularly during sleep or when engaging in activities that could cause direct contact with the area.
Choice C rationale: Obtaining the client's blood pressure in either arm is not the appropriate approach, as the arm with the arteriovenous fistula should not be used for blood pressure measurements or any other procedures that could damage the fistula. Blood pressure should be measured in the non-access arm to ensure the integrity of the vascular access and minimize the risk of complications.
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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