A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Place the client in a reclining chair.

Put locks at top of doors.

Encourage physical activity prior to bed time.

Position the mattress on the floor.

Install sensor devices on outside doors.

Answer and Explanation

Correct Answer : B,C,D,E

A.   Placing the client in a reclining chair is not recommended as it does not prevent wandering or falls and may even restrict movement leading to discomfort or pressure sores.
B.   Putting locks at the top of doors can prevent the client from wandering outside, which reduces the risk of falls and getting lost, especially during the night.
C.   Encouraging physical activity prior to bedtime can help in expending energy which may lead to better sleep and reduce restlessness and wandering at night.
D.   Positioning the mattress on the floor can minimize injury from falls that may occur when the client attempts to get out of bed during the night.
E.   Installing sensor devices on outside doors can alert the caregiver if the client attempts to leave the house, which is crucial for preventing wandering and potential falls.

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Correct Answer is A

Explanation

A. Consistency in staffing helps establish a therapeutic relationship and promotes trust and predictability, which can improve social interactions for clients with borderline personality disorder.
B. Exploring feelings of abandonment may be appropriate in therapy sessions but is not specifically aimed at improving social interactions.
C. Discussing maladaptive behaviors and working towards behavior change is important in the treatment of borderline personality disorder and should not be avoided.
D. Encouraging dependent behaviors can perpetuate maladaptive patterns and hinder progress in treatment for clients with borderline personality disorder.

A. Discuss the provider's goals for the client's care. B. Ask the client if the medication is causing adverse effects. C. Request the provider prescribe a second antipsychotic medication to the client. D. Tell the client they will be admitted to an inpatient care facility if they do not take the medication.

Correct Answer is B

Explanation

A. Discussing the provider's goals for the client's care may be helpful but does not directly address the client's reported non-adherence or potential barriers to medication compliance.
B. Asking the client if the medication is causing adverse effects allows the nurse to assess for potential reasons why the client is not taking the medication regularly, such as side effects or discomfort, and address those concerns.
C. Requesting a second antipsychotic medication without addressing the client's reasons for non- adherence may not effectively improve medication compliance and could increase the risk of adverse effects or drug interactions.
D. Threatening the client with admission to an inpatient care facility is coercive and may not address the underlying reasons for non-adherence, potentially worsening the therapeutic
relationship and trust.

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Body system	Findings
Neurological	Impaired cognition

	Insomnia Seizures
Cardiovascular	Increased blood pressure Increased heart rate Diaphoresis
Gastrointestinal	Lack of appetite Vomiting
Musculoskeletal	Malaise Tremulousness

A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has borderline personality disorder. Which of the following interventions should the nurse plan to include to assist the client with impaired social interactions with others?

Correct Answer is A

Explanation

A nurse is assessing a client during a follow-up visit at a behavioral health clinic. The client reports that they have not been taking the prescribed antipsychotic medication on a regular basis. Which of the following actions should the nurse take to improve medication adherence?

Correct Answer is B

Explanation

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