A client is showing early signs of dementia. The client's spouse asks, "What may I expect next?" What is the nurse's best response?
"He may begin to try to cover recognition of his memory loss by creating events."
"He may have difficulty in a motor skill such as walking."
"The inability to communicate with speech comes immediately after the early signs."
"He may not recognize you and other people who have been in his life."
The Correct Answer is A
A. "He may begin to try to cover recognition of his memory loss by creating events." As
dementia progresses, individuals may experience confabulation, which involves creating false memories to compensate for memory loss. This is a common symptom seen in the middle stages of dementia.
B. "He may have difficulty in a motor skill such as walking." While motor skills may be affected in the later stages of dementia, it is not typically one of the early signs.
C. "The inability to communicate with speech comes immediately after the early signs." This statement is not accurate. Communication difficulties may occur in later stages, but it is not an immediate progression from early signs.
D. "He may not recognize you and other people who have been in his life." This symptom, known as agnosia, may occur in later stages of dementia, but it is not one of the early signs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Placing the client on one-on-one observation while monitoring for suicidal ideations Given that the client is experiencing auditory hallucinations commanding self harm and is refusing to commit to a safety plan, one-on-one observation is necessary to ensure the client's safety. This
intervention provides constant monitoring and allows for immediate intervention if self harm is attempted.
B. Conducting 15minute checks to ensure safety While conducting regular safety checks is
important, in this case, more continuous monitoring is required due to the severity of the client's symptoms.
C. Encouraging the client to verbalize feelings related to suicide While encouraging communication is essential, in this urgent situation, immediate safety measures take precedence.
D. Completing a room search to ensure there are no harmful objects available to the client
Ensuring the environment is safe is important, but it should be done in conjunction with one-on- one observation to provide the highest level of safety for the client.
Correct Answer is B
Explanation
A) Incorrect. While understanding if the client is experiencing a relapse is important, knowing the timing of the last drink is crucial for assessing the level of intoxication.
B) Correct. Knowing the time of the last drink helps the nurse gauge the current level of alcohol in the client's system, which is crucial in assessing and managing alcohol intoxication.
C) Incorrect. While understanding the duration of the client's problem with alcohol is important, it is not the most immediate concern when the client is showing symptoms of intoxication.
D) Incorrect. Asking about liver problems is relevant but not the first priority when the client is exhibiting signs of alcohol intoxication.
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