Nokea
A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer’s disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include?
- A. Position the mattress on the floor
- B. Install sensor devices on outside doors
- C. Encourage physical activity prior to bedtime
- D. Put locks at top of doors
Correct Answer: A
Rationale: The correct answer is A: Position the mattress on the floor. Placing the mattress on the floor reduces the risk of injury if the client falls out of bed while wandering at night. This option prioritizes safety by minimizing the distance of potential falls. Installing sensor devices on outside doors (B) may alert the caregiver but does not directly address the risk of falls. Encouraging physical activity prior to bedtime (C) could increase agitation and wandering behavior. Putting locks at the top of doors (D) could pose a safety risk if emergency access is needed.
You may also like to solve these questions
A nurse is planning care for a 3-year-old child who has autism spectrum disorder. Which of the following findings should the nurse expect?
- A. Readily initiates conversation
- B. Enjoys imaginative play
- C. Strong relationship with sibling and peers
- D. Attachment to objects that spin
Correct Answer: D
Rationale: The correct answer is D: Attachment to objects that spin. Children with autism spectrum disorder often exhibit repetitive behaviors, such as spinning objects, as a way to self-soothe or seek sensory stimulation. This behavior can serve as a coping mechanism and provide a sense of control for the child. Other choices are incorrect because children with autism spectrum disorder may have challenges in initiating conversations (A), engaging in imaginative play (B), or forming strong relationships with siblings and peers (C). By understanding the characteristics of autism spectrum disorder, the nurse can better tailor care and interventions to support the child's unique needs.
A nurse is providing teaching to the caregiver of a client who has schizophrenia. Which of the following statements by the caregiver indicates an understanding of the teaching?
- A. I should reinforce reality when my loved one is experiencing delusions.'
- B. I should discourage my loved one from expressing feelings.'
- C. I should avoid talking to my loved one about his hallucinations.'
- D. I should encourage my loved one to isolate when symptoms occur.'
Correct Answer: A
Rationale: The correct answer is A: "I should reinforce reality when my loved one is experiencing delusions." This statement indicates an understanding of the teaching because it aligns with the therapeutic approach of reality orientation, which helps the client differentiate between reality and delusions. By reinforcing reality, the caregiver can help the client manage their symptoms effectively.
Choices B, C, and D are incorrect because they promote behaviors that are not beneficial for a client with schizophrenia. Discouraging the expression of feelings (B) can lead to emotional suppression. Avoiding discussion about hallucinations (C) may prevent the caregiver from understanding the client's experiences. Encouraging isolation (D) can worsen symptoms and hinder social interaction, which is important for recovery.
A nurse in a psychiatric unit is planning care for a client who has paranoid personality disorder. Which of the following interventions should the nurse include?
- A. Encourage group therapy participation
- B. Avoid challenging the client’s paranoid beliefs
- C. Maintain eye contact during conversations
- D. Use humor to reduce the client’s anxiety
Correct Answer: B
Rationale: The correct answer is B: Avoid challenging the client’s paranoid beliefs. This is essential because challenging the client's beliefs can lead to increased defensiveness and mistrust. Instead, the nurse should validate the client's feelings without reinforcing the delusions. Encouraging group therapy (choice A) may exacerbate paranoia by increasing feelings of being scrutinized. Maintaining eye contact (choice C) may be perceived as threatening. Using humor (choice D) could be misinterpreted and lead to further distrust.
A nurse is planning care for a client with acute delirium. Which of the following instructions should the nurse include in the plan?
- A. Reinforce the clients orientation with the calendar
- B. Refute the clients perception of visual hallucinations
- C. Teach the client assertive techniques
- D. Assign the client to a different caregiver each shift
Correct Answer: A
Rationale: The correct answer is A: Reinforce the client's orientation with the calendar. This is because in acute delirium, the client may experience confusion and disorientation. Using a calendar can help provide structure and aid in orientation. Choice B is incorrect as refuting hallucinations may worsen the client's agitation. Choice C is incorrect as assertive techniques are not typically used in managing acute delirium. Choice D is incorrect as consistency in caregivers is important for continuity of care in delirium management.
A nurse is caring for a client who has schizophrenia and takes clozapine. Which of the following findings is a priority for the nurse to report to the provider?
- A. Nausea
- B. Random blood glucose 130 mg/dL
- C. Heart rate 104 per minute
- D. Sore throat
Correct Answer: D
Rationale: The correct answer is D: Sore throat. A priority finding to report with clozapine is agranulocytosis, which presents with symptoms like sore throat. This is crucial to detect early to prevent severe infection. A: Nausea is a common side effect of clozapine but not a priority over potential agranulocytosis. B: Random blood glucose of 130 mg/dL is slightly elevated but not an immediate concern. C: Heart rate of 104 per minute may be a side effect but is not as critical as agranulocytosis. Reporting the sore throat promptly can lead to timely intervention and prevent serious complications.