The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which is the best action by the nurse?
A Keep window blinds open during the day
B Have the patient take a mid-morning nap.
C Provide hourly orientation to time and place.
D Move the patient to a quiet room in the afternoon.
The Correct Answer is A
Choice A Rationale: Keeping window blinds open during the day is a non pharmacological approach to help regulate the patient's circadian rhythm and may reduce the severity of sundowning, a common phenomenon in dementia.
Choice B Rationale: Having the patient take a mid-morning nap may disrupt the patient's sleep-wake cycle and worsen sundowning.
Choice C Rationale: Providing hourly orientation to time and place may be overwhelming for the patient and not necessarily effective in addressing sundowning.
Choice D Rationale: Moving the patient to a quiet room in the afternoon may not address the underlying issue of sundowning and may not be practical in a long-term care setting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Rationale: Assessing the client for bladder distention is the first and most crucial step in managing autonomic dysreflexia. Bladder distention is a common trigger for this condition in clients with spinal cord injuries. Identifying and addressing the cause (bladder distention) is the priority to prevent further complications.
Choice B Rationale: Laying the client flat may not resolve the underlying cause of autonomic dysreflexia and should be done after identifying and addressing the trigger.
Choice C Rationale: Obtaining the client's heart rate is important but should come after assessing for bladder distention since the primary concern in autonomic dysreflexia is elevated blood pressure due to a noxious stimulus.
Choice D Rationale: Administering a nitrate antihypertensive may be necessary if other interventions do not resolve the blood pressure elevation, but it should not be the first action. Identifying and addressing the cause, such as bladder distention, is the priority.
Correct Answer is B
Explanation
Choice A Rationale: Sedatives may not be the first choice for managing behavioral issues in clients with Alzheimer's disease, as they can increase confusion and fall risk.
Choice B Rationale: Antipsychotics may be considered in cases where behavioral issues pose a safety concern. They can help manage agitation, aggression, and other challenging behaviors.
Choice C Rationale: Cholinesterase inhibitors are used to treat cognitive symptoms of Alzheimer's disease but may not directly address behavioral issues.
Choice D Rationale: Serotonin reuptake inhibitors are typically used to manage mood disorders and may not be the first-line choice for behavioral issues in Alzheimer's disease.
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