1. A nurse in a LTC facility notices a client who has Alzheimer’s disease standing at the exit door at the end of the hallway. The client appears to be anxious & agitated. What action should the nurse take?

ANS: Escort the client to a quiet area on the nursing unit.

- A client c Alzheimer experiences chronic confusion. Guiding the client to a quiet, familiar area will help decrease agitation. They will be unable to follow instructions/commands.

2. A nurse is assisting with the plan of care for a client who has a continent urinary diversion. Which intervention should the nurse plan to implement to facilitate urinary elimination?

ANS: Use intermittent urinary catheterization for the client at regular intervals.

- A continent urinary diversion contains valves that prevent urine from exiting the pouch; therefore, the nurse should plan to insert a urinary catheter at regular intervals to drain urine from the client’s pouch.

3. A nurse is assisting with an education program about car restraint safety for a group of parents. Which statement by the parent indicates an understanding of the instructions?

ANS: “My 12YO child should place the shoulder-lap seatbelt low across his hips.”

- When a child is old enough to only use a shoulder-lap seatbelt, he should place it low across his hips rather than over the abdomen to reduce risk for injury during motor vehicle crash.

4. A nurse is reinforcing teaching about strategies to promote eating with a client who has COPD. Which instructions should the nurse include in the teaching?

ANS: Drink high-protein and high-calorie nutritional supplements.