Practice Quiz

NCLEX-RN

Category - Care Management

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Nina the New Nurse is planning the care of a client admitted for nephritis; the client also has a history of Alzheimer’s disease, with periods of agitation. Which of the following measures would be appropriate for this client’s plan of care?
  1. Side rails up at all times; keep stimulation to minimum.
  2. Apply restraints, as needed for agitation. Monitor daily.
  3. Keep client busy with simple, repetitive tasks. Keep client in a wheelchair at nurses’ station while awake.
  4. Assign client to room near nurses’ station. Have frequent visits by nursing team. Provide soothing music while awake.
Explanation
Answer: D - Keeping the client in a room near the nurses’ station facilitates frequent checks by nursing. Overstimulation may increase agitation, but some stimulation is necessary for reality orientation. Providing soothing music may help meet this need.
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