A client with Alzheimer's disease is admitted to an acute care facility for treatment of an infection. Assessment reveals that the client is anxious
When developing the client's plan of care, which of the following would be least appropriate for a nurse to include?
A) Frequently provide reality orientation
B) Simplify the client's routines
C) Limit the number of choices to be made
D) Establish predictable routines
The threshold for stress is progressively lowered in people with Alzheimer's disease and other progressive dementias. A healthy person frequently uses cognitive coping strategies when under stress, but a person with dementia can no longer use many of these strategies. Commonly used therapeutic approaches may exacerbate anxiety in a client with dementia. For example, reality orientation is usually an effective intervention for acutely confused clients. Reality orientation is contraindicated in those with dementia because it is possible that the client's disoriented behavior or language has inherent meaning. If the disoriented behavior or language is continuously neglected or corrected, the client's sense of isolation and anxiety may increase. Effective nursing interventions include simplifying routines, making routines as consistent and predictable as possible, reducing the number of choices the client must make, identifying areas in which control can be maintained, and creating an environment in which the client feels safe.
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When the nurse prepares to give ferrous sulfate (Feosol) to a home health patient, the nurse will:
1. mix the drug with a high-protein milk shake. 2. give undiluted with a small snack. 3. mix with coffee or cola to disguise the bitter taste. 4. dilute and offer through a straw and a few crackers.
Which phrase best describes neuromuscular dissociation?
a. Loosening taut muscles when touched by another person b. Contracting and consciously releasing different muscle groups c. Relaxing while someone is applying pressure against a tendon or large muscle d. Relaxing the rest of the body while one group of muscles is strongly contracted
A manic client who tends to be manipulative says angrily, "You had better let me out of here, or I'm going to call my lawyer. My boss has good friends with the owners of this tin-pot place you call a 'mind holism respite.'" Which statement by the nurse would be most therapeutic?
A. "When you can speak to me without yelling and being aggressive, I'll be happy to speak with you." B. "Just get your anger out with me, because we're not going to allow you be discharged until you calm down." C. "Do threats and name-calling usually work for you? Do people tend to listen to you and do as you order them to?" D. "I know that you feel that you're doing your very best right now, but you are yelling. Take some time out and some deep breaths, and I'll speak to you in half an hour."
When administering an eye medication, the nurse should:
A. Clean away crusts from the outer to inner canthus B. Place eye drops directly onto the sclera C. Apply ointment along the inner edge of the lower eyelid D. Rub the eye gently, in a circular motion, after giving eye drops