An older client with Alzheimer's disease is confused and asking the nurse to call their mother who is deceased. Which nonpharmacological intervention should the nurse implement?

Clarify reality with the client about delusional thoughts.

Reduce the client's interaction with others during day.

Use distraction and therapeutic communication skills.

Awaken the client for reality checks every 4 hours at night.

Answer and Explanation

The Correct Answer is C

A)   Incorrect- Clarify reality with the client about delusional thoughts: Attempting to correct the client's delusional thoughts might cause frustration and agitation. Clients with Alzheimer's disease may have difficulty comprehending and retaining reality-based information.
B)   Incorrect- Reduce the client's interaction with others during the day: Social interaction is important for clients with Alzheimer's disease to maintain engagement and prevent feelings of isolation. Reducing interaction could worsen their emotional well-being.
C)   Correct- Clients with Alzheimer's disease often experience cognitive impairments and may have delusional thoughts or confusion, such as believing deceased loved ones are still alive. Nonpharmacological interventions are crucial to provide comfort and manage challenging behaviors. Distraction techniques involve redirecting the client's attention away from the delusion and onto a different, engaging activity. This can help decrease distress and anxiety related to their delusional thoughts. Therapeutic communication skills, such as validating the client's feelings and emotions, can also be beneficial. Simply telling the client that their mother is deceased may cause distress and confusion. Instead, providing comfort, empathizing with their emotions, and redirecting their focus can be more effective in managing the situation.
D)   Incorrect- Awaken the client for reality checks every 4 hours at night: Disrupting the client's sleep schedule could lead to increased confusion and restlessness. It's important to provide a calm and consistent sleep routine for individuals with Alzheimer's disease.

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Correct Answer is A

Explanation

A.Tingling on the tongue or lips is an early sign of an allergic reaction to the contrast dye used during an intravenous pyelogram. This type of reaction can quickly progress to more severe symptoms, such as difficulty breathing and anaphylaxis, so it is crucial to recognize and respond to it promptly.

B. Episodes of shivering: Shivering is not typically an early sign of an allergic reaction to contrast dye. It might indicate a reaction to temperature or anxiety but is not as immediately concerning as symptoms of an allergic reaction.

C. Salty taste in the mouth: A salty or metallic taste is a common and benign side effect of the contrast dye and is not indicative of an adverse reaction.

D. Difficulty breathing: Difficulty breathing is a severe and later sign of an allergic reaction. By the time this symptom appears, the reaction has progressed and immediate intervention is necessary.

A. A salad with three kinds of lettuce and fruit. B. Vegetable soup, crackers, and milk. C. A peanut butter sandwich with soda and cookies. D. A tuna fish sandwich with chips and ice cream.

Correct Answer is D

Explanation

A) Incorrect - While a salad includes vegetables and fruits, it may not provide sufficient protein for wound healing.
B) Incorrect - Vegetable soup and crackers might not provide enough protein compared to other options.
C) Incorrect - While a peanut butter sandwich includes some protein, soda and cookies are not rich sources of protein.

D) Correct- A tuna fish sandwich is a good source of protein. Protein is essential for wound healing as it supports tissue repair and regeneration. The choice of a tuna fish sandwich along with chips and ice cream suggests a balanced meal with adequate protein content, which aligns with the teaching of a high protein diet to promote wound healing.

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An older client with Alzheimer's disease is confused and asking the nurse to call their mother who is deceased. Which nonpharmacological intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult client is admitted for severe pain in his side and back and is sent for an intravenous pyelogram. Which report from the client is the earliest indication to the nurse that the client is experiencing an adverse reaction to this procedure?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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