A home nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan monitor?
Hemoglobin and hematocrit
Liver function tests
Kidney function tests
Serum sodium and potassium
The Correct Answer is D
A. Hemoglobin and hematocrit are important but not the focus in Alzheimer’s care unless anemia is suspected.
B. Liver function tests are not typically monitored unless the client is on hepatotoxic medications.
C. Kidney function tests are essential if there are concerns about hydration or medication clearance but are not routine in Alzheimer's care.
D. Monitoring serum sodium and potassium is critical as imbalances can lead to confusion, agitation, and worsening cognitive symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"},"E":{"answers":"A,B"},"F":{"answers":"A,B"}}
Explanation
Assessment findings |
Placenta previa |
Abruptio placenta |
Pain score |
✅ |
|
Vaginal bleeding characteristics |
✅ |
|
Hematocrit |
✅ |
✅ |
Abdominal assessment |
✅ |
|
Hemoglobin |
✅ |
✅ |
Blood pressure |
✅ |
✅ |
Rationale:
Pain: The client has abdominal pain, rated 7/10, which is sharp and associated with uterine hypertonicity and tenderness in the left upper quadrant. Placenta previa typically presents with painless bleeding and minimal to no abdominal pain, while abruptio placenta involves severe pain due to placental separation.
Vaginal bleeding: Dark red vaginal bleeding was reported. Placenta previa results in painless bright red bleeding, while abruptio placenta presents with dark red bleeding often accompanied by clots and associated pain.
Hemoglobin: Hemoglobin is 8.1 g/dL, which is low (normal range: 12 to 16 g/dL), indicating blood loss or hemorrhage. Both conditions can lead to low hematocrit and hemoglobin, but abruptio placenta may cause more significant blood loss, leading to a greater decrease in these values.
Hematocrit: The hematocrit is 24%, which is also low (normal range: 36% to 47%), further suggesting blood loss. Both conditions can lead to low hematocrit and hemoglobin, but abruptio placenta may cause more significant blood loss, leading to a greater decrease in these values.
Abdominal assessment: Placenta previa tends to show a soft abdomen with no tenderness, while abruptio placenta causes rigid, board-like abdominal muscles with tenderness, often localized.
Blood Pressure: Blood pressure is 95/62 mm Hg, which is on the lower side but not critically low. Placenta previa typically has normal or slightly low blood pressure, while abruptio placenta can cause hypotension due to significant blood loss and shock.
Fetal Heart Rate: FHR is 116/min, with minimal variability noted, which may indicate fetal distress which can be seen in both conditions.
Correct Answer is B
Explanation
A. Belief in being reunited with the child is a common and healthy coping mechanism.
B. Inability to experience joy (anhedonia) is a key symptom of major depressive disorder and warrants further assessment.
C. Feeling guilty is a normal part of grief but does not necessarily indicate major depression.
D. Anger is a normal stage of grief and does not typically indicate a disorder unless prolonged or extreme.
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