A nurse is reinforcing teaching about environmental modifications in the home with a family member of a client who has Alzheimer's disease. Which of the following information should the nurse include in the teaching?

Leave the television on.

Install locks at the top of doors.

Place throw rugs on the floor.

Schedule alternate caregivers.

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Leaving the television on is incorrect. Constant background noise from the television might be overwhelming and confusing for someone with Alzheimer's. It's generally better to have a quiet and calming environment to reduce agitation and confusion.

Choice B Reason:

Installing locks at the top of doors is correct. This can be an essential safety measure to prevent the person from wandering or accessing unsafe areas. Installing locks higher up on doors can help prevent the individual from opening doors and wandering into potentially dangerous situations.

Choice C Reason:

Placing throw rugs on the floor is incorrect. Throw rugs pose a tripping hazard, especially for individuals with Alzheimer's who might have mobility issues or difficulties with depth perception. Removing throw rugs or securing them firmly to the floor is essential to prevent falls.

Choice D Reason:

Scheduling alternate caregivers is incorrect. While having alternate caregivers is important for support, it doesn't directly relate to environmental modifications within the home.

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Correct Answer is C

Explanation

Choice A Reason:

A client whose injection site is scabbed is incorrect. Scabbing at the injection site does not provide information about the presence or absence of induration. It doesn't contribute to interpreting the test result directly.

Choice B Reason:

A client whose injection site is firm and measures 3 mm (0.1 in) is incorrect. A measurement of 3 mm of induration is generally considered a negative result for most individuals, including those without any risk factors for tuberculosis (TB).

Choice C Reason:

A client whose injection site has an elevated area measuring 15 mm (0.6 is correct. An area of induration measuring 15 mm or more is considered positive in individuals with no known risk factors for TB.

Choice D Reason:

A client whose injection site is ecchymotic is incorrect. Ecchymosis (bruising) at the injection site is not relevant to the interpretation of the tuberculin skin test. It does not contribute to determining a positive or negative result.

A. Locate the injection site 5 cm (2 in) to the right or left of the umbilicus. B. Check the medication administration record to verify the client's allergies. C. Slowly inject the medication into the site without aspirating. D. Pinch clean skin at the injection site and dart the needle into the skinfold at a 90° angle. E. Ensure an air bubble is present in the prefilled enoxaparin syringe.

Correct Answer is B, E, A, D, C

Explanation

B. Check the medication administration record to verify the client's allergies. Before preparing or administering any medication, the nurse must verify the client’s medication order and allergies to ensure safety. E. Ensure an air bubble is present in the prefilled enoxaparin syringe. The prefilled syringe contains an air bubble that should remain to ensure the entire dose is administered and to prevent medication from tracking back through the tissue. A. Locate the injection site 5 cm (2 in) to the right or left of the umbilicus. Enoxaparin should be administered in the subcutaneous tissue of the abdomen, avoiding areas near the umbilicus to reduce the risk of irritation and bruising. D. Pinch clean skin at the injection site and dart the needle into the skinfold at a 90° angle. Pinching the skin ensures the medication is delivered into the subcutaneous tissue, and injecting at a 90° angle minimizes pain and ensures proper technique. C. Slowly inject the medication into the site without aspirating. Aspiration is not necessary for subcutaneous injections. Slowly injecting reduces discomfort and ensures proper absorption.

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A nurse is reinforcing teaching about environmental modifications in the home with a family member of a client who has Alzheimer's disease. Which of the following information should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An occupational health nurse is interpreting the results of a tuberculin skin test for a group of clients who received the test 48 hr ago. Which of the following clients should the nurse identify as having a positive test result?

Correct Answer is C

Explanation

A nurse is preparing to administer subcutaneous enoxaparin. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is B, E, A, D, C

Explanation

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