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 D

Explanation

Choice A rationale:

The client does not need an oxygen mask for a low flow rate of 1 to 2 L/min. Oxygen masks are typically used for higher flow rates and may not be comfortable or necessary for a client requiring such a low oxygen flow.

Choice B rationale:

A reservoir bag is not required for a client receiving low flow oxygen at 1 to 2 L/min. Reservoir bags are commonly used with oxygen masks at higher flow rates to ensure a consistent supply of oxygen during inhalation.

Choice C rationale:

Petroleum jelly is not a necessary supply for a client prescribed home oxygen at 1 to 2 L/min. Its use may not be recommended due to the risk of flammability in the presence of oxygen.

Choice D rationale:

The correct choice is D. The client should have a nasal cannula as a supply upon discharge. A nasal cannula is the appropriate delivery device for low flow oxygen therapy at 1 to 2 L/min. It is comfortable and allows for adequate oxygen supplementation for the client.

A. Black out the line with a felt-tip pen. B. Leave the space as it is within the entry. C. Draw a horizontal line through the space and sign at the end of the line. D. Place the date at the beginning of the space, followed by double lines.

Correct Answer is C

Explanation

Choice A rationale:

Blacking out the line with a felt-tip pen is not an appropriate action for correcting a blank space in the nurses' notes. It can make the entry look unprofessional and may not be accepted as a proper correction.

Choice B rationale:

Leaving the space as it is within the entry is not the correct action because it does not address the blank space or provide necessary documentation. Blank spaces in documentation should be corrected appropriately.

Choice C rationale:

Drawing a horizontal line through the space and signing at the end of the line is the correct action. This is a standard practice for correcting blank spaces in documentation. It signifies that the space was intentionally left blank and has been reviewed and approved by the nurse.

Choice D rationale:

Placing the date at the beginning of the space, followed by double lines, is not a standard or recommended method for correcting blank spaces in documentation. It can lead to confusion and may not meet documentation standards.

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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?