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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Orienting the client to the unit While orientation is important, the client's prolonged
immobility and stupor necessitate a physical assessment first to ensure there are no underlying medical issues contributing to this state.

B. Reinforcing reality with the client The client's catatonic state may make it difficult to effectively communicate or engage in reality orientation at this point. Addressing potential physical issues is the initial priority.

C. Establishing a nonthreatening relationship Building a therapeutic relationship is crucial, but given the client's current state, assessing for physical problems takes precedence.

D. Assessing the client for physical problems The client's prolonged catatonic state requires an
immediate physical assessment to rule out any underlying medical conditions contributing to his condition.

A. "Why don't you discuss that with your physician?" B. "I would rather you reconsider that decision." C. "What happened the last time you stopped taking your medication?" D. "The physician prescribed that medication to help you."

Correct Answer is D

Explanation

A. This response may be seen as evading the client's statement. It's important to provide a more direct response.
B. This response may come across as controlling or confrontational, which may not promote open communication.
C. This response is a good therapeutic technique as it encourages the client to reflect on past experiences with stopping medication.
D. This response provides a clear and factual statement about the purpose of the prescribed medication, encouraging the client to understand its importance.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 28-year old male admitted with catatonic schizophrenia has been mute and motionless for several days while at home prior to admission. He still appears stuporous in the hospital. Which nursing intervention would be an initial priority?

Correct Answer is D

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Which of the following is the most therapeutic response by the nurse when a client states, "I no longer need my medication since I do not hear voices"?

Correct Answer is D

Explanation

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