A patient with Alzheimer's disease (AD) who is being admitted to a hospital rehab facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care?
Ask the patient why the wandering episodes have occurred
Place the patient in a room close to the nurse's station
Reorient the patient several times daily
Have the family bring in familiar items
The Correct Answer is B
Choice A reason: Asking the patient why the wandering episodes have occurred might not be effective because patients with Alzheimer's disease often have memory and cognitive impairments that make it difficult for them to understand or articulate the reasons for their behavior. Additionally, it may not address the immediate safety concerns associated with wandering.
Choice B reason: Placing the patient in a room close to the nurse's station is a practical and effective measure to enhance patient safety. Proximity to the nurse's station allows for closer supervision and quicker response if the patient attempts to wander. This action helps prevent potential accidents and ensures that the patient receives timely interventions if needed. It is a proactive approach to managing the wandering behavior commonly seen in patients with Alzheimer's disease.
Choice C reason: Reorienting the patient several times daily is an important aspect of care for individuals with Alzheimer's disease, as it can help reduce confusion and anxiety. However, this alone may not be sufficient to prevent wandering. While reorientation is beneficial, the immediate safety of the patient requires additional measures, such as close supervision.
Choice D reason: Having the family bring in familiar items can provide comfort and a sense of security for the patient, which is important in managing Alzheimer's disease. Familiar objects may help reduce anxiety and agitation, but they do not directly address the safety concerns associated with wandering. This action should be part of a comprehensive care plan that includes measures to prevent wandering and ensure patient safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Observing for signs of hypotension is not typically a primary concern for patients with Cushing syndrome. These patients are more likely to experience hypertension due to increased cortisol levels, which cause sodium and water retention, rather than hypotension. Therefore, while monitoring blood pressure is important, focusing specifically on hypotension is not relevant to the typical presentation of Cushing syndrome.
Choice B reason: Monitoring blood glucose levels is a crucial intervention for patients with Cushing syndrome. Increased cortisol levels lead to hyperglycemia and glucose intolerance. Patients may develop diabetes mellitus as a result of chronic hypercortisolism. Regular monitoring of blood glucose levels helps in managing and controlling hyperglycemia and adjusting medication as necessary to maintain stable glucose levels.
Choice C reason: Protecting the patient from exposure to infection is essential in caring for patients with Cushing syndrome. Elevated cortisol levels suppress the immune system, making patients more susceptible to infections. Implementing infection control measures, such as hand hygiene, using personal protective equipment, and monitoring for signs of infection, are vital to prevent complications and ensure patient safety.
Choice D reason: Restricting protein intake is not a recommended intervention for patients with Cushing syndrome. In fact, these patients often require a diet high in protein to counteract the muscle wasting and weakness caused by excessive cortisol levels. Adequate protein intake helps in maintaining muscle mass and overall health, making restriction counterproductive.
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A reason: Sedatives and opioids are known to cause delirium, especially in older adults or those with compromised health. These medications can affect the central nervous system, leading to confusion and cognitive impairment.
Choice B reason: Alcohol use, particularly in combination with withdrawal, can lead to delirium. Alcohol affects neurotransmitter function and can cause significant changes in mental status when consumed in excess or withdrawn abruptly.
Choice C reason: Untreated pain can contribute to delirium, particularly in patients who are already vulnerable due to age or underlying health conditions. Pain can cause significant stress on the body and mind, leading to confusion and cognitive dysfunction.
Choice D reason: Sleep deprivation is a significant factor in the development of delirium. Lack of sleep can impair cognitive function and increase the risk of delirium, especially in hospitalized patients or those with pre-existing cognitive impairments.
Choice E reason: Sensory overload, such as exposure to loud noises, bright lights, or unfamiliar environments, can contribute to delirium. Patients with sensory impairments or those in unfamiliar settings are particularly at risk.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.