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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
The client has a delayed response to verbal commands. This finding can indicate increased intracranial pressure. Changes in responsiveness, such as delayed responses to verbal commands or other stimuli, can be indicative of neurological impairment due to elevated pressure within the skull.
Choice B Reason:
The client has ecchymosis around the eyes. Ecchymosis around the eyes (raccoon eyes) can occur with certain head injuries, but it's not a direct sign of increased intracranial pressure. It's more commonly associated with basilar skull fractures rather than specifically reflecting increased pressure within the skull.
Choice C Reason:
The client is unable to remember details of the motor-vehicle crash. Memory impairment or amnesia regarding the event can occur due to head trauma, but it might not directly correlate with an increase in intracranial pressure. It's more related to the effects of the injury on memory function.
Choice D Reason:
The client reports ringing in the ears. Tinnitus or ringing in the ears might occur in some cases of head trauma but is not a direct indicator of increased intracranial pressure. It might result from the impact of the injury or other associated factors.
Correct Answer is C
Explanation
Choice A Reason:
Administer meperidine IM is incorrect. Reason why it's not the answer: Meperidine (Demerol) is not recommended in cases of malignant hyperthermia. It can potentially exacerbate the situation by further increasing muscle rigidity and potentially contributing to the hypermetabolic state. Meperidine can trigger additional release of calcium from the sarcoplasmic reticulum in muscles, worsening the symptoms.
Choice B Reason:
Instill a warm enema solution is incorrect. Reason why it's not the answer: Introducing warm solutions can exacerbate the client's condition by further increasing body temperature. Malignant hyperthermia is characterized by a dangerous increase in body temperature, and adding heat through an enema would only make the situation worse.
Choice C Reason:
Applying a cooling blanket is recommendable. Reason why it's the answer: A cooling blanket is a recommended intervention for managing malignant hyperthermia. Lowering the body temperature is crucial in preventing further complications associated with the high fever. Cooling blankets help dissipate heat from the body, aiding in rapidly reducing the dangerously elevated temperature associated with malignant hyperthermia.
Choice D Reason:
Ventilate client with 50% oxygen is incorrect. Reason why it's not the answer: While providing oxygen support might be necessary as part of managing the overall condition, ventilating with 50% oxygen specifically may not directly address the core issue of rapidly cooling the body during a malignant hyperthermia crisis. Ventilation may be required, but the immediate concern is to cool the body to prevent complications arising from the elevated body temperature.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today