An older female resident of a long-term care facility with early-stage Alzheimer's disease frequently wanders into the wrong room. To help this client recognize her room, which intervention should the nurse implement?

Leave the door open so she recognizes her belongings.

Place a picture of the client on her door.

Put a bright red balloon on the client's door.

Enlarge the letters of her name on the door.

Answer and Explanation

The Correct Answer is B

Choice A reason: Leaving the door open so the client recognizes her belongings might help, but it is not the most effective solution. It relies on the client being able to remember and identify her possessions, which can be challenging with Alzheimer's disease.

Choice B reason: Placing a picture of the client on her door is an effective intervention. It provides a clear visual cue that the client can easily recognize, helping her to identify her own room without relying on memory alone. This approach uses a personal and familiar image, making it easier for the client to find her room.

Choice C reason: Putting a bright red balloon on the client's door may attract attention but does not provide a personal or meaningful cue for the client. While it might help distinguish the door, it lacks the personal connection needed for effective recognition.

Choice D reason: Enlarging the letters of her name on the door can help, but it still relies on the client's ability to read and recognize her name, which may be impaired. A picture of the client is a more straightforward and effective visual aid.

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Correct Answer is B

Explanation

Choice A reason: These vital signs are within normal limits and do not indicate an immediate concern that requires reporting to the healthcare provider.

Choice B reason: This set of vital signs shows a heart rate of 110 beats/minute, which is tachycardia, and a blood pressure of 88/56 mmHg, which is hypotension. Both of these findings, combined with the client's fever, could indicate sepsis or other complications that require immediate attention.

Choice C reason: These vital signs are relatively stable and do not indicate a critical issue that requires immediate reporting.

Choice D reason: While these vital signs show an elevated respiratory rate, they are not as critical as the vital signs in Choice B, which show hypotension and tachycardia.

A. Reduce the client's interaction with others during the day. B. Awaken the client for reality checks every 4 hours at night. C. Clarify reality with the client about delusional thoughts. D. Use distraction and therapeutic communication skills.

Correct Answer is D

Explanation

Choice A reason: Reducing the client's interaction with others during the day can potentially isolate the client and exacerbate feelings of agitation and confusion. Social interaction is important for cognitive stimulation and emotional well-being, even for clients with Alzheimer's disease.

Choice B reason: Awaking the client for reality checks every 4 hours at night can disrupt the client's sleep pattern, leading to increased agitation and confusion. Proper rest is crucial for clients with Alzheimer's disease to help manage their symptoms effectively.

Choice C reason: Clarifying reality with the client about delusional thoughts can sometimes increase agitation if not done sensitively. Clients with Alzheimer's disease may not respond well to direct confrontation about their delusions. It is often more effective to use techniques that do not directly challenge their perception of reality.

Choice D reason: Using distraction and therapeutic communication skills is the best approach. This strategy helps redirect the client's attention to a different, more calming activity, which can reduce agitation. Therapeutic communication involves understanding and validating the client's feelings while gently guiding them towards a more positive state. This approach respects the client's experience and provides support without escalating their agitation.

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An older female resident of a long-term care facility with early-stage Alzheimer's disease frequently wanders into the wrong room. To help this client recognize her room, which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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