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 D
Explanation
Choice A Rationale: Fecal incontinence is not typically associated with mild Alzheimer's disease but may occur in later stages.
Choice B Rationale: Urinary incontinence can occur in Alzheimer's disease, but it is not specific to the mild stage.
Choice C Rationale: Inability to smile is not a typical manifestation of Alzheimer's disease but may be related to facial muscle weakness or other factors.
Choice D Rationale: Being able to drive to familiar places is consistent with the early stage of Alzheimer's disease, where clients may still have some independence and ability to perform routine tasks.
Correct Answer is B
Explanation
Choice A Rationale: Anticipating intubation is not warranted solely based on an O2 saturation of 92% and without further assessment.
Choice B Rationale: Asking the client to cough, then inhale and exhale deeply is an appropriate initial action to improve oxygenation and assess the client's respiratory status.
Choice C Rationale: Inserting an intravenous catheter is unrelated to the client's O2 saturation and would not address the immediate concern.
Choice D Rationale: Administering antihypertensives is not indicated based on the O2 saturation level, and it may not be safe without further assessment.
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