Review Practice Exercise 2

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Practice Exercise 2

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Total Questions : 3

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Question 1:

A nurse is making a home visit to a client who has AD. The client’s partner states that the client is often disoriented to time and place, is unsteady on his feet, and has a history of wandering. Which of the following safety measures should the nurse review with the partner? Select all that apply

A. Remove floor rugs. B. Have door locks that can be easily opened. C. Provide increased lighting in stairwells. D. Install handrails in the bathroom. E. Place the mattress on the floor.

Answer and Explanation

Choice A:

Remove floor rugs: Rugs can be a major tripping hazard for unsteady individuals. Their removal reduces the risk of falls.

Choice B:

Have door locks that can be easily opened: Easy-to-open locks can increase wandering risk, leading to unsafe exits. Doors should have childproof or high-mounted locks to prevent elopement while ensuring emergency access.

Choice C:

Provide increased lighting in stairwells: Poor lighting contributes to falls and disorientation, especially in unfamiliar or transitional areas. Bright lighting improves visibility and safety.

Choice D:

Install handrails in the bathroom: Bathrooms are common sites of falls; handrails provide support during transfers and ambulation. They promote independence and reduce injury risk.

Choice E:

Place the mattress on the floor: For clients who wander or may fall out of bed, lowering the bed reduces injury from falls. It is a practical solution to maintain safety while avoiding restraints.

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Question 2:

A nurse is caring for a client who has AD and falls frequently. Which of the following actions should the nurse take first to keep the client safe?

A. Keep the call light near the client. B. Place the client in a room close to the nurses’ station. C. Encourage the client to ask for assistance. D. Remind the client to walk with someone for support.

Answer and Explanation

Choice A:

Keep the call light near the client: Clients with AD may forget to use the call light or may not recognize its purpose. While helpful, this is not the most reliable first action.

Choice B:

Place the client in a room close to the nurses’ station: Proximity allows for frequent visual monitoring and quicker intervention. This is the most immediate and effective strategy to prevent falls in high-risk clients.

Choice C:

Encourage the client to ask for assistance: Due to cognitive decline, the client may be unable to remember or follow through with this instruction. Encouragement alone is insufficient.

Choice D:

Remind the client to walk with someone for support: Verbal reminders may not be retained or understood by clients with AD. Physical supervision is more effective than verbal cues.

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Question 3:

A nurse working in a long-term care facility is planning care for a client in stage 5 of Alzheimer’s disease. Which of the following interventions should be included in the plan of care?

A. Use a gait belt for ambulation. B. Thicken all liquids. C. Provide protective undergarments. D. Assist with ADLs.

Answer and Explanation

Choice A:

Use a gait belt for ambulation: Gait belts may be useful, but not all clients at stage 5 require them. It depends on individual mobility status, which is not universally impaired at this stage.

Choice B:

Thicken all liquids: Thickened liquids are typically used in later stages (6 or 7) when swallowing difficulty (dysphagia) becomes pronounced. This intervention is premature in stage 5 unless otherwise indicated.

Choice C:

Provide protective undergarments: Incontinence generally becomes more common in stage 6 or 7. Most clients in stage 5 still retain some bladder and bowel control.

Choice D:

Assist with ADLs: Clients in stage 5 may forget how to perform tasks like dressing or bathing. Providing help with ADLs ensures safety, hygiene, and comfort.

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Practice Exercise 2

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