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 C
Explanation
A. The Michigan Alcohol Screening Test (MAST) is a tool used to screen for alcohol abuse or dependence, but it does not specifically assess withdrawal symptoms.
B. The CAGE questionnaire is used to screen for alcohol abuse, but it does not assess withdrawal symptoms.
C. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is a validated tool used to assess the severity of alcohol withdrawal symptoms. It includes various criteria such as agitation, tremor, and hallucinations.
D. The Delirium Rating Scale (DMSE) is used to assess the severity of delirium, which can be caused by various factors including alcohol withdrawal, but it is not specific to alcohol withdrawal.
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.
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