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A client who is in Stage II of Alzheimer's disease has memory impairment. The nurse should plan to do which of the following at the beginning of the upcoming work shift?

1. Check to ensure that the client is wearing an ID badge.
2. Place the client in a quiet, calm environment.
3. Write a note on the cover of the chart asking for a prn order for restraints.
4. Instruct ancillary caregivers to assess the client's level of consciousness hourly.

Explanation

Nurses caring for clients who have Alzheimer's disease should ensure that these clients are wearing an identification bracelet so they do not become lost if they wander. It is unnecessary to assess LOC hourly, and restraints are also not indicated. It is not essential that the client be placed in a quiet, calm environment; rather, they often prefer to be allowed to move about at will. Recall that wandering is a concern for clients with Alzheimer’s.

Contributor

Andrew
Member since: April 2011
(Boynton Beach,FL) Original question source

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Topics: Adult Health: Neurological, Nursing Process: Planning

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