A client diagnosed with Alzheimer's disease has a catastrophic reaction during an activity involving simultaneous music playing and a craft project. The client starts shouting, "No! No! No!" and runs from the room
The nurse should implement which approach? 1. Intervene one-on-one with the client until the client is calm, and then redirect the client to the activity
2. Follow the client, reassure the client one-on-one, and then redirect the client to a less stimulating activity
3. Discontinue the activity program since it is upsetting the clients
4. Administer a PRN anti-anxiety medication and restrict the client's activity participation
2. Follow the client, reassure the client one-on-one, and then redirect the client to a less stimulating activity
Rationale:
Environmental stimulus should be kept at a minimum for clients with dementia. A quiet environment will prevent sensory overload. The nurse's one-on-one intervention with the client will reassure the client and reduce anxiety. Once the client is less agitated, the client can be directed to a less stimulating activity.
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Another nurse responds that this is not important since nurses are required to provide compassionate care for all people in all circumstances. The responding nurse has displayed what concept? a. Beneficence b. Advocacy c. Confidentiality d. Autonomy
A get up and go test involves having the patient rise from a chair, walk 20 feet, turn and walk back to the examiner. This should be completed within____ seconds
A. 10 B. 15 C. 20 D. 25
Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/LVN)?
a. Complete the initial admission assessment and plan of care. b. Document teaching completed before a diagnostic procedure. c. Instruct a patient about low-fat, reduced sodium dietary restrictions. d. Obtain bedside blood glucose on a patient before insulin administration.
When teaching a client newly diagnosed with type 1 diabetes, the nurse recognizes the need for further teaching when the client responds:
a. "I don't need to wear gloves when I administer my insulin shots." b. "I need to rotate my insulin injection sites to prevent lipodystrophy." c. "If I inject my insulin in a site I seldom use, it may cause my blood sugar to drop too much." d. "As long as I keep a mental schedule of rotating injection sites, I don't need to keep a written record."