A nurse is providing teaching for the family of a client who has Alzheimer's disease. Which of the following statements should the nurse include?

"Display a monthly calendar in the client's room."

"Provide plenty of stimulation in the client's room."

"Keep the client's room dark at night to promote sleep."

"Provide the client with structured activities to fill their time."

Answer and Explanation

The Correct Answer is A

Choice A reason : Displaying a monthly calendar can help orient a client with Alzheimer's disease to the date and assist with maintaining a sense of time, which can be beneficial in managing cognitive impairment.

Choice B reason: Providing plenty of stimulation can be overwhelming for clients with Alzheimer's disease. A calm and predictable environment is usually more beneficial.

Choice C reason: Keeping the room dark at night can promote sleep, but it is not the only consideration. A nightlight or low-level lighting can prevent falls if the client needs to get up during the night.

Choice D reason: Providing structured activities can help fill the client's time and provide a sense of purpose, but it should be tailored to the individual's abilities and preferences.

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Correct Answer is B

Explanation

Choice A reason : Administering corticosteroids is not the first-line action for dyspnea related to fluid overload or other causes of respiratory distress in this context.

Choice B reason : Slowing the infusion rate is appropriate when there are signs of fluid overload, such as dyspnea and hypertension. Contacting the provider is crucial for further assessment and management, which may include diuretics or other interventions.

Choice C reason : Lowering the head of the bed to semi-Fowler's may provide some relief for dyspnea, but it does not address the potential cause, which in this case could be fluid overload.

Choice D reason : Changing the infusion to lactated Ringer's would not be appropriate if the client is experiencing symptoms of fluid overload. The type of fluid is less important than the volume and rate of administration in this scenario.

A. Decreased urinary output B. Emesis of 250 mL C. Decreased anxiety D. Increased respiratory rate to 26/min

Correct Answer is C

Explanation

Choice A reason: Decreased urinary output is not a direct indicator of morphine's effectiveness in acute heart failure. While morphine can lead to urinary retention, this is generally considered a side effect rather than an intended therapeutic outcome.

Choice B reason: Emesis, or vomiting, of 250 mL is not an indication of morphine's effectiveness. In fact, nausea and vomiting are common side effects of morphine and other opioids. If emesis occurs, it may necessitate further intervention.

Choice C reason: Decreased anxiety is a sign that the morphine is effective. Morphine has anxiolytic properties, meaning it can help alleviate anxiety, which is beneficial in acute heart failure where anxiety can exacerbate symptoms like shortness of breath.

Choice D reason: An increased respiratory rate to 26/min is not an indication of morphine's effectiveness and is a cause for concern. Morphine can depress the respiratory system, and an increased respiratory rate may indicate compensation for hypoxemia or the onset of adverse effects.

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A nurse is providing teaching for the family of a client who has Alzheimer's disease. Which of the following statements should the nurse include?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hours. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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