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. Attempting to deescalate the client is important, but ensuring immediate safety is the top priority.
B. Continuing to observe the client may lead to a further escalation of the situation. Safety measures should be taken first.
C. While offering medications may be necessary, ensuring safety is the immediate priority before any interventions are implemented.
D. Ensuring the safety of the client and others is the priority in situations of escalating agitation.

A. Plan to discuss any topic that is presented. B. Focus on client weaknesses to increase adaptation. C. Provide continuity of care by assigning the same staff. D. Allow client to determine the boundaries of the nurse client relationship.

Correct Answer is C

Explanation

A) Incorrect. While discussing various topics is important, providing continuity of care is more crucial in creating a therapeutic environment for clients with paranoia and schizophrenia.

B) Incorrect. Focusing on client strengths rather than weaknesses is generally a more effective approach in mental health care.

C) Correct. Providing continuity of care by assigning the same staff helps build trust and a sense of security for clients, especially those with paranoia and schizophrenia.
D) Incorrect. While it's important to establish boundaries, allowing the client to solely determine them may not always be in their best interest.

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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

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Correct Answer is C

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