An older adult in the middle and late stages of Alzheimer's forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the client's family?
Label the bathroom door.
Take the older adult to the bathroom hourly.
Place the older adult in disposable adult briefs.
Limit the intake of oral fluids to 1000 mL/day.
The Correct Answer is A
A. Labeling the bathroom door can provide a visual cue to help the older adult locate the bathroom, which may reduce episodes of incontinence.
B. Taking the older adult to the bathroom hourly is a good strategy, but it may not always be feasible or effective in preventing accidents.
C. Using disposable adult briefs may be necessary at times, but it should not be the first line intervention.
D. Limiting oral fluids to 1000 mL/day may lead to dehydration and is not an appropriate intervention for addressing incontinence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Agitation can be a sign of distress, but sudden cheerfulness may be indicative of a decision to act on suicidal thoughts, as the individual may feel relieved to have made a decision.
B. Sudden cheerfulness can be a concerning sign, as it may indicate that the client has made a decision to carry out suicidal thoughts.
C. Psychomotor retardation is a symptom of depression and may not necessarily indicate imminent risk of suicide.
D. Not attending group therapy may be a sign of withdrawal or isolation, but it does not directly indicate immediate suicidal risk.
Correct Answer is D
Explanation
A. Neologisms refer to made-up words or phrases that have meaning only to the individual. The client's response does not include invented terms but rather consists of real words that are nonsensically grouped.
B. Echolalia is the repetition of words or phrases spoken by others. The client's response does not reflect repetition of the nurse's words but rather a disjointed response of their own.
C. Pressured speech involves rapid and often incoherent speech that reflects a sense of urgency. The client's response lacks the rapid flow characteristic of pressured speech.
D. Clang association is characterized by speech in which the individual connects words based on their sound rather than their meaning. The client's response ("medications, abbreviations, deviations, mediations") demonstrates this pattern, as the words are linked by similar sounds rather than by content or coherent thought.
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