The nurse is caring for a client who is being admitted to the hospital with a neurocognitive disease due to Alzheimer's disease. Which action by the nurse is the priority?

Ensuring that the client takes care of their ADLS to prevent dependence.

Ensuring that the client environment is safe to prevent injury.

Ensuring that the client receives food they like to prevent anxiety.

Ensuring that the client meets the other patients to prevent social isolation.

Answer and Explanation

The Correct Answer is B

A. Ensuring that the client takes care of their ADLS to prevent dependence: While promoting independence is important, ensuring safety is a higher priority to prevent immediate harm.
B. Ensuring that the client environment is safe to prevent injury: Safety is the top priority for clients with Alzheimer's due to their increased risk of falls, wandering, and other accidents. A safe environment helps prevent injuries.
C. Ensuring that the client receives food they like to prevent anxiety: Although providing familiar and preferred foods can reduce anxiety, it is not as critical as ensuring a safe environment.
D. Ensuring that the client meets the other patients to prevent social isolation: Social interaction is beneficial, but ensuring safety takes precedence to prevent potential harm.

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Correct Answer is B

Explanation

A. The baseline FHR can be obtained via ultrasound or auscultation: True. The baseline fetal heart rate can be assessed using ultrasound or auscultation, which are standard methods.
B. The baseline FHR can be obtained during contractions: False. The baseline fetal heart rate should be obtained in the absence of uterine contractions because contractions can temporarily alter the heart rate, making it difficult to determine the true baseline.
C. The baseline FHR is normal between 110-160 bpm: True. This is the accepted normal range for baseline fetal heart rates.
D. The baseline FHR is assessed over a 10-minute period: True. The baseline is typically assessed over a 10-minute window to account for variability and provide an accurate average.

A. Keep eye shields on at all times, including when feeding B. Routinely monitor temperature while infant is in the crib C. Tightly swaddle the infant in blanket D. Expose as much of the infant's skin to the lights as possible

Correct Answer is D

Explanation

A. Keep eye shields on at all times, including when feeding. Incorrect because while eye protection is crucial under the lights, they can be removed during feedings to allow for parent-infant bonding and eye contact.
B. Routinely monitor temperature while the infant is in the crib. Incorrect, because temperature should be closely monitored while the infant is under phototherapy due to potential changes in body temperature caused by the exposure.
C. Tightly swaddle the infant in a blanket. Incorrect, as this would reduce the amount of skin exposed to the phototherapy lights and decrease the treatment's effectiveness.
D. Expose as much of the infant's skin to the lights as possible. Phototherapy is most effective when as much skin as possible is exposed to the lights because it allows for maximum light absorption and more effective bilirubin breakdown.

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The nurse is caring for a client who is being admitted to the hospital with a neurocognitive disease due to Alzheimer's disease. Which action by the nurse is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following statements is NOT true about baseline fetal heart rates (FHR)?

Correct Answer is B

Explanation

An 18-hour-old infant with hyperbilirubinemia is placed under phototherapy bank lights. Which of the following is an appropriate intervention for this infant?

Correct Answer is D

Explanation

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