A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include?

Cover electrical outlets in the client's home with tape.

Hang a monthly calendar in the client's bedroom.

Keep the client's bedroom dark at night.

Place a large-face clock in the client's bedroom.

Answer and Explanation

The Correct Answer is B

A monthly calendar can help the client with Alzheimer's disease to orient to time and date and reduce confusion and anxiety. The nurse should encourage the family to use simple and clear reminders and cues to assist the client with daily activities and routines.

Covering electrical outlets with tape is not necessary and may pose a fire hazard. Keeping the client's bedroom dark at night may increase the risk of falls and injuries. A large-face clock may be helpful, but not as much as a calendar.

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Correct Answer is A

Explanation

The nurse should instruct the client to use a 10-mL syringe or larger to flush the PICC line with normal saline or heparin solution, as prescribed, to prevent occlusion and thrombosis. The other options are incorrect because they may cause complications such as infection, phlebitis, or bleeding.

A. Pupillary dilation B. Decorticate posturing C. Altered level of consciousness D. Cheyne-Stokes respirations

Correct Answer is C

Explanation

Altered level of consciousness (LOC) is the earliest and most sensitive indicator of increased ICP, which can result from brain injury, tumor, hemorrhage, infection, or edema.

The nurse should monitor the client's LOC using the Glasgow Coma Scale (GCS) and report any changes or deterioration to the provider. Pupillary dilation, decorticate posturing, and Cheyne-Stokes respirations are later signs of increased ICP that indicate brainstem compression and herniation, which are life-threatening emergencies.

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A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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