The nurse is caring for an older adult client with Alzheimer's disease who becomes increasingly agitated and is speaking to someone who is not visible to the nurse. Which action should the nurse implement?

Reduce the client's interaction with others during the day.

Awaken the client for reality checks every 4 hours at night.

Clarify reality with the client about delusional thoughts.

Use distraction and therapeutic communication skills.

Answer and Explanation

The Correct Answer is D

Choice A reason: Reducing the client's interaction with others during the day can potentially isolate the client and exacerbate feelings of agitation and confusion. Social interaction is important for cognitive stimulation and emotional well-being, even for clients with Alzheimer's disease.

Choice B reason: Awaking the client for reality checks every 4 hours at night can disrupt the client's sleep pattern, leading to increased agitation and confusion. Proper rest is crucial for clients with Alzheimer's disease to help manage their symptoms effectively.

Choice C reason: Clarifying reality with the client about delusional thoughts can sometimes increase agitation if not done sensitively. Clients with Alzheimer's disease may not respond well to direct confrontation about their delusions. It is often more effective to use techniques that do not directly challenge their perception of reality.

Choice D reason: Using distraction and therapeutic communication skills is the best approach. This strategy helps redirect the client's attention to a different, more calming activity, which can reduce agitation. Therapeutic communication involves understanding and validating the client's feelings while gently guiding them towards a more positive state. This approach respects the client's experience and provides support without escalating their agitation.

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Correct Answer is B

Explanation

Choice A reason: Stool with fatty streaks is not a common finding in ulcerative colitis. It is more associated with malabsorption syndromes.

Choice B reason: Blood in the stool is a significant finding in ulcerative colitis, especially during an acute exacerbation. It indicates active inflammation and potential bleeding in the colon, which requires immediate attention and intervention.

Choice C reason: Clay-coloured stool usually indicates a problem with the bile ducts or liver, such as bile duct obstruction. It is not specific to ulcerative colitis.

Choice D reason: Hard pellets of stool indicate constipation, which is not typically associated with ulcerative colitis, especially during an acute exacerbation where diarrhea is more common.

A. Notify the charge nurse that the client will need assignment to the COVID-19 specified area of the facility. B. Place the nasal swab specimen for COVID-19 directly into a biohazard bag. C. Maintain a 6 feet (1.8 meters) distance from the client unless wearing an N95 respirator and personal protective equipment (PPE) for droplet precautions. D. Start an intravenous infusion for an antiviral drug to be administered for positive COVID-19 test results.

Correct Answer is C

Explanation

Choice A reason: Notifying the charge nurse that the client will need assignment to the COVID-19 specified area of the facility is an important action for infection control. However, the most immediate priority is to protect oneself and others by maintaining appropriate distance and using PPE.

Choice B reason: Placing the nasal swab specimen for COVID-19 directly into a biohazard bag is necessary for safe specimen handling and to prevent contamination. While important, it follows after ensuring that proper PPE is used and distancing measures are maintained.

Choice C reason: Maintaining a 6 feet (1.8 meters) distance from the client unless wearing an N95 respirator and personal protective equipment (PPE) for droplet precautions is the most crucial action. This step ensures the nurse’s safety and reduces the risk of virus transmission. Proper PPE and distancing protocols are essential in managing a suspected COVID-19 case.

Choice D reason: Starting an intravenous infusion for an antiviral drug to be administered for positive COVID-19 test results is part of the treatment plan if the test comes back positive. However, this step comes after ensuring safety through proper use of PPE and maintaining distance from the client.

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The nurse is caring for an older adult client with Alzheimer's disease who becomes increasingly agitated and is speaking to someone who is not visible to the nurse. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with ulcerative colitis is admitted to the medical unit during an acute exacerbation. The nurse should instruct the unlicensed assistive personnel (UAP) to report which finding related to the client's bowel movements?

Correct Answer is B

Explanation

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Correct Answer is C

Explanation

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