In planning care for a client with early stage Alzheimer's disease, the nurse establishes the nursing problem of risk for injury related to impaired judgment. Which intervention is most important for the nurse to include in this client's plan of care?
Engage the client in regularly scheduled activities during the day.
Offer the client frequent reassurance that he/she will be safe.
Arrange the client's environment so the client can move about freely.
Assign a UAP to provide the client with total personal care.
The Correct Answer is C
Clients with early-stage Alzheimer's disease may experience impaired judgment and cognitive decline, which can increase their risk for injury. Arranging the client's environment in a way that allows them to move about freely helps promote their safety and reduces the risk of accidents or falls.
Engaging the client in regularly scheduled activities during the day is a beneficial intervention as it provides structure and stimulation for the client. However, it may not directly address the risk for injury related to impaired judgment.
Offering the client frequent reassurance that they will be safe is important to provide emotional support, but it may not be sufficient in preventing physical harm or addressing the specific nursing problem of risk for injury.
Assigning a UAP (Unlicensed Assistive Personnel) to provide the client with total personal care may be helpful in assisting with activities of daily living. However, it does not directly address the risk for injury related to impaired judgment, and the nurse should have a central role in coordinating and overseeing the client's care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The property of the drugs that, if shared by both, indicates a need to closely monitor the client for drug toxicity is:
Highly protein bound.
When a drug is highly protein bound, it means that a significant portion of the drug molecules bind to proteins in the bloodstream. This binding can affect the availability and distribution of the drug in the body. If two drugs are highly protein bound and administered together, they may compete for binding sites on the proteins, leading to increased levels of unbound (free) drug in the bloodstream. This can result in higher drug concentrations and an increased risk of drug toxicity.
Closely monitoring the client for drug toxicity is necessary when drugs are highly protein bound because there is a potential for increased drug levels and associated adverse effects. Monitoring for signs and symptoms of drug toxicity, as well as routine laboratory tests to assess liver and kidney function, may be necessary in these cases.
The other properties listed do not necessarily indicate a need for closer monitoring for drug toxicity:
- Low bioavailability refers to the fraction of an administered dose that reaches the systemic circulation in an active form. While low bioavailability can affect the effectiveness of a drug, it does not directly imply a need for closer monitoring for drug toxicity.
- Short half-life refers to the time it takes for half of the drug concentration in the body to be eliminated. While drugs with short half-lives may require more frequent dosing, this property does not inherently suggest a need for closer monitoring for drug toxicity.
- High therapeutic index indicates a wide margin of safety for a drug, meaning that the effective dose is significantly lower than the toxic dose. A high therapeutic index implies that the drug has a wide safety margin and is less likely to cause drug toxicity.
Correct Answer is A
Explanation
Assessing and managing pain is a crucial aspect of providing atraumatic care for any post-operative patient, including a child. The child cried throughout the procedure and will likely experience discomfort and pain after the surgery. It is important to assess the child's pain levels regularly using appropriate pain assessment tools and provide appropriate pain management interventions to ensure their comfort and well-being.
While antibiotics may be prescribed if there is a surgical site infection or specific indications for their use, it is not mentioned as a priority in this scenario. The focus is on providing atraumatic care post-operatively, and pain assessment takes precedence.
Occupational therapy, physical therapy, and wound care are important components of the child's overall care, but they may not be the immediate priority post-operatively.
These interventions can be incorporated into the plan of care as needed, but addressing pain is of utmost importance in the immediate post-operative period.
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