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A nurse is reinforcing teaching with the caregiver of a client who has Alzheimer's disease. The caregiver reports that the client awakens at night and wanders. Which of the following strategies should the nurse suggest?
- A. Place a lock at the top of doors leading outside.
- B. Use light restraints while the client is in bed.
- C. Administer an antianxiety medication before bedtime.
- D. Encourage the client to nap during the day.
Correct Answer: A
Rationale: Placing a lock at the top of doors helps prevent the client from wandering outside, ensuring safety. This is a practical, non-restrictive measure to manage nighttime wandering in Alzheimer’s.
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A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication. The client has prescriptions for an anxiolytic and an SSRI antidepressant. Which of the following precautions should the nurse take?
- A. Implement 24-hr one-to-one nursing observation.
- B. Document the client's behavior every 2 hr.
- C. Restrict interactions with other clients.
- D. Administer prescribed medication via the IM route.
Correct Answer: A
Rationale: Implementing 24-hr one-to-one nursing observation is crucial for ensuring the safety of a client who has overdosed and is at risk of self-harm. This provides constant monitoring given the high-risk situation.
A nurse is caring for a client who has depression and reports only sleeping a few hours each night. Which of the following instructions should the nurse give the client to promote sleep?
- A. You should drink a glass of wine 1 hour before you go to bed.
- B. You should eat a meal just prior to bedtime.
- C. You should take a nap after lunch.
- D. You should limit yourself to two caffeinated beverages per day.
Correct Answer: D
Rationale: Limiting caffeine intake to two beverages per day can promote better sleep. Caffeine is a stimulant that can interfere with falling asleep and staying asleep, especially if consumed later in the day. This instruction supports improved sleep quality.
Nurses' Notes
Admission: Client restless during the night, attempting to get out of bed and placing bedcovers on the floor. Has been incontinent of urine twice. Client instructed on use of urinal and told to call for assistance by using the call light. Confuses the call light with the television remote control. Disoriented to time, place, person, and situation. Unable to recall home address. Was unable to assist with bath this morning; when handed the washcloth to clean their face, client asked, "Do you want me to put this in the dryer?"
Medical History
A 76-year-old client fell at home, resulting in fractured humerus and multiple abrasions to arms. Client is unable to recall what precipitated the fall, and physical examination reveals no injury to the client's head. Client has a history of hypertension controlled with atenolol. Client lives with partner and adult children visit client every few months.
A nurse is caring for a 76-year-old female client who experienced a fall.Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to collect data about the client's progress.
- A. Expected aging process,Alzheimer's disease,Major depressive disorder,Delirium
- B. Determine the date of the client's last eye examination,Use symbols rather than written signs for directions, Anticipate a prescription for donepezil,Anticipate a prescription for duloxetine.
- C. Night vision,Presence of agnosia,Ability to complete familiar tasks,Oxygen saturation
Correct Answer: B
Rationale: Alzheimer’s explains chronic confusion and task difficulty. Using symbols aids navigation, donepezil manages symptoms, and monitoring agnosia and familiar tasks tracks progression.
A nurse is reinforcing teaching with a client who started taking haloperidol decanoate 125 mg IM 1 month ago. Which of the following statements by the client should the nurse address?
- A. I check my blood pressure once a week.
- B. I chew sugar-free gum several times daily.
- C. I haven't had a drink of alcohol since I started taking these injections.
- D. I spend several hours a day outside gardening when it's sunny.
Correct Answer: D
Rationale: Spending several hours outside in the sun could increase the risk of photosensitivity, a side effect of haloperidol. The nurse should address this to educate the client on protective measures like sunscreen use.
A nurse is caring for a client who has depressive disorder following the recent death of their partner. Which of the following responses should the nurse make?
- A. Everyone feels depressed during the grieving process.
- B. I remember how depressed I was after my friend died.
- C. You should start participating in your usual activities.
- D. Tell me what your relationship with your partner was like.
Correct Answer: D
Rationale: Asking about the client’s relationship encourages them to express their feelings and helps the nurse understand their experience to provide support. This fosters a therapeutic dialogue.