A client with Alzheimer's disease in the intensive treatment unit ...

[jake]

A client with Alzheimer's disease in the intensive treatment unit repeatedly tries to go into other patients' rooms to nap during the day. The most appropriate nursing intervention for this patient is what?
 
  A) Allowing her to nap in an empty room
  B) Explaining to her why this cannot be tolerated
  C) Escorting the patient to her room for napping
  D) Suggesting that daytime napping be decreased

Question 2

A 22-year-old woman has presented to the emergency department early in the morning and tearfully admitted to the triage nurse that she was sexually assaulted by two men after being drugged in a club the night before.
 
  The nurse would prioritize which of the following nursing diagnoses in the care of this client?
 
  A) Spiritual distress
  B) Anxiety
  C) Ineffective coping
  D) Rape trauma syndrome

[14vl19]

Answer to Question 1

Ans: C
Allowing the client to nap in an empty room would disrupt unit activity because of frequent bed changes and does not serve any therapeutic purpose. Explaining to the client why this behavior cannot be tolerated would be ineffective, because the client has memory impairment and would not remember not to go into the rooms of others. Escorting the client to her room for napping allows the client her own space and reinforces the reality of her personal room. Unless daytime napping interferes with nighttime sleep, there is no reason to eliminate short napping periods.

Answer to Question 2

Ans: D
The nursing diagnosis of rape trauma syndrome is used when a client experiences a forced, violent sexual assault against his or her will and without his or her consent. The trauma syndrome develops as a result of the attack or attempted attack. Ineffective coping is not evidenced by the client's response to the gravity of the assault, and anxiety and spiritual distress may be components of rape trauma syndrome.