A client diagnosed with Alzheimer's disease has a catastrophic reaction during an activity in-volving simultaneous playing of music and working on a craft project. The client starts shouting "no, no, no" and rushes out of the room. The nurse sho
1. Isolate the client until she is calm, and then direct her back to the activity
2. Follow the client, reassure her, and redirect her to a quieter activity
3. Discontinue the activity program since it upsets the clients
4. Give the client prn antianxiety medication and restrict her activity participation
ANS: 2
These actions will restore safety and self-esteem. 1. Isolation will decrease self-esteem and may increase confusion. 3. It is only one client who is distressed. 4. Behavioral interventions should be attempted prior to administering medication.
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Postural hypotension is defined as a ___________________ when the patient stands compared with sitting or supine readings
a. systolic pressure drop of more than 15 mm Hg with a pulse rate increase b. pulse rate decrease with a systolic pressure increase of at least 15 mm Hg c. diastolic pressure increase of more than 5 mm Hg and no pulse rate changes d. pulse rate decrease and diastolic pressure decrease of more than 5 mm Hg
A nurse educating a new mother on how to bathe her infant uses the acronym TEACH to maximize the effectiveness of the education plan. Which of the following are guidelines based on this acronym? Select all that apply
A) Tune out the individual client. B) Edit client information. C) Act on every teaching moment. D) Always refer a client to counseling. E) Clarify often.
A client has developed blisters around the tape that secures the dressing. The nurse should:
A) apply tape to the side of the blisters. B) use Montgomery straps. C) apply the dressing with a binder. D) apply skin barrier to protect skin.
The nurse is teaching a client with preterm premature rupture of membranes (PPROM) regarding self-care activities. Which activities should the nurse include in her teaching?
a. Report a temperature higher than 40° C. b. Tampons are safe to use to absorb the leaking amniotic fluid. c. Do not engage in sexual activity. d. Taking frequent tub baths is safe.