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 D

Explanation

A. Weighing the client every other day may contribute to increased anxiety and fixation on weight, which is not recommended for clients with binge eating disorder.
B. Remaining with the client for 1 hour after meals may not be feasible or practical and may not directly address the underlying issues associated with binge eating disorder.
C. Offering snacks when the client is hungry may not address the underlying psychological issues driving binge eating behavior and may inadvertently reinforce unhealthy eating patterns.

D. Planning a menu with the client promotes collaboration, empowers the client to make healthier food choices, and fosters a sense of control over their eating habits, which are important aspects of managing binge eating disorder.

A. Blood alcohol level B. Client's recent loss C. Smoking history D. Client's recent consumption of alcohol E. Cardiac assessment F. Neurological assessment G. Genitourinary assessment H. Respiratory assessment I. Gastrointestinal assessment

Correct Answer is ["A","B","D","F","I"]

Explanation

A. The blood alcohol level of 510 mg/dL indicates severe intoxication and requires monitoring for potential complications, such as respiratory depression or alcohol withdrawal.

B. The client's recent loss of both parents is significant and may contribute to the relapse of alcohol use disorder. It warrants further assessment of the client's coping mechanisms and emotional state.
C. Smoking history:

While the client's smoking history may be relevant to their overall health, it is not a priority for follow-up in this scenario where the client's alcohol intoxication and potential withdrawal symptoms are the primary concerns.
D. The client's recent consumption of alcohol, as reported by the family member, is crucial information for assessing the risk of alcohol withdrawal and planning appropriate
interventions.

E. Cardiac assessment:
The client's vital signs indicate normal sinus rhythm and stable blood pressure, suggesting no acute cardiac issues at present. Given the focus on alcohol intoxication and potential withdrawal, a comprehensive cardiac assessment is not immediately warranted.
F. The neurological assessment is essential to monitor for signs of alcohol withdrawal, such as tremors, hallucinations, or seizures, given the client's history of alcohol use disorder and current intoxication.
G. Genitourinary assessment:

While assessing the genitourinary system is important in a comprehensive nursing assessment, there are no indications in the provided information to suggest acute genitourinary issues requiring immediate follow-up. The client's current symptoms and history primarily suggest alcohol intoxication and potential withdrawal.
H. Respiratory assessment:

The client's respiratory assessment indicates clear lung sounds and adequate oxygen saturation, suggesting no acute respiratory distress at the time of admission. While
respiratory status should be monitored, it is not a priority for immediate follow-up compared to the client's alcohol intoxication and potential withdrawal.
I. Assessing the gastrointestinal system is important to evaluate the client's nutritional status, assess for signs of liver disease or other gastrointestinal complications associated with alcohol use disorder, especially considering the reported weight loss and minimal appetite.

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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.)

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a binge eating disorder. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse in a mental health facility is admitting a client. Exhibits A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

Correct Answer is ["A","B","D","F","I"]

Explanation

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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.)

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