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 D

Explanation

Choice A reason: Serum potassium of 5.0 me/L and serum sodium of 138 me/L are within normal ranges and do not reflect the expected electrolyte imbalances due to dehydration from vomiting and diarrhea.

Choice B reason: Serum potassium of 4.5 me/L and serum sodium of 140 me/L are also within normal ranges. This does not reflect the typical imbalance caused by dehydration.

Choice C reason: Serum potassium of 3.5 me/L and serum sodium of 142 me/L are normal values. They do not indicate the electrolyte disturbances expected with dehydration from vomiting and diarrhea.

Choice D reason: Serum potassium of 3.0 me/L indicates hypokalaemia (low potassium), and serum sodium of 149 me/L indicates hypernatremia (high sodium). These imbalances are expected in a client with a history of fever, vomiting, and diarrhea, as these conditions can lead to loss of potassium and concentration of sodium due to dehydration.

A. Bounding peripheral pulse. B. uneven hair distribution. C. Lower leg enema. D. bronze pigmentation.

Correct Answer is B

Explanation

Choice A reason: A bounding peripheral pulse indicates increased arterial circulation and is not a sign of compromised peripheral arterial circulation. In cases of arterial insufficiency, pulses may actually be diminished or absent.

Choice B reason: Uneven hair distribution is a classic sign of compromised peripheral arterial circulation. Poor blood flow to the extremities can lead to decreased hair growth, causing patchy or uneven hair distribution. This symptom is often seen in clients with peripheral arterial disease.

Choice C reason: Lower leg enema is more commonly associated with venous insufficiency rather than arterial insufficiency. Edem results from fluid accumulation due to poor venous return rather than issues with arterial circulation.

Choice D reason: Bronze pigmentation is often related to chronic venous insufficiency and hemosiderin deposition in the skin. It is not typically a sign of compromised arterial circulation. Arterial issues are more likely to cause pallor or cyanosis in the affected extremity.

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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

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