A nurse in a long-term care facility is assessing a client who has dementia. Which of the following findings should the nurse identify as a risk for this client?

Hallways are long distances

The room has an area rug

The bed is in a low position

Outside doors have locks

Answer and Explanation

The Correct Answer is A

A. Hallways are long distances:
Long hallways can be challenging for individuals with dementia due to their potential mobility issues, disorientation, and decreased ability to navigate. Dementia often affects spatial awareness and can lead to confusion, making it difficult for patients to find their way back to their rooms or common areas. Long distances increase the risk of falls and disorientation.

B. The room has an area rug:
Area rugs can present tripping hazards for anyone, especially for individuals with mobility issues, balance problems, or cognitive impairments like dementia. Patients might trip on the edges of the rug, leading to falls and injuries.

C. The bed is in the low position:
Having the bed in a low position is generally considered a safety measure, especially for patients at risk of falls. However, for a patient with dementia, it might be important to strike a balance. Beds that are too low can be difficult for individuals with dementia to get in and out of, potentially leading to falls. It's important to assess the patient's ability to safely get in and out of bed.

D. Outside doors have locks:
Locks on outside doors are essential for the safety of individuals with dementia. Dementia patients are prone to wandering, which can lead them to dangerous situations if they leave the facility unsupervised. Locks on outside doors help prevent wandering, ensuring the patients stay within the secure confines of the facility.

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Correct Answer is B

Explanation

A. Rambling speech
Rambling speech is not a typical finding associated with depression. It may indicate other conditions or issues.

B. Insomnia
Insomnia, or difficulty sleeping, is a common symptom of depression. Many individuals with depression experience trouble falling asleep, staying asleep, or both.

C. Rapid mood swings
Rapid mood swings are not typically associated with depression. Depression often involves persistent low mood rather than rapid fluctuations.

D. Sundowning
Sundowning refers to a state of confusion and restlessness that occurs in the late afternoon and evening, often seen in individuals with dementia. While it can be related to mood disturbances, it's not specific to depression.

A. "Did you experience any childhood trauma?" B. "Are you the result of a twin birth?" C. "Have you ever purposefully lost a job?" D. "Did your parent have a viral infection while pregnant with you?"

Correct Answer is C

Explanation

A. "Did you experience any childhood trauma?"
Childhood trauma, such as abuse or neglect, can contribute to various mental health conditions, including post-traumatic stress disorder (PTSD), depression, or anxiety disorders. While trauma can impact a person's mental health, it does not directly assess the risk for alcohol use disorder.

B. "Are you the result of a twin birth?"
Being a twin or the result of multiple births does not inherently indicate a risk for alcohol use disorder. This question is related to an individual's birth status and has no direct connection to the assessment of alcohol-related issues.

C. "Have you ever purposefully lost a job?"
This is the correct choice. Purposefully losing a job might indicate behavioral issues related to alcohol misuse or impairment. Individuals with alcohol use disorder may engage in behaviors that lead to job loss, such as absenteeism, poor performance, or conflict at the workplace due to alcohol consumption.

D. "Did your parent have a viral infection while pregnant with you?"
Prenatal viral infections can potentially affect fetal development and lead to certain health conditions. However, this question is not directly related to the risk of alcohol use disorder. Alcohol use disorder is primarily influenced by environmental factors, genetic predisposition, and individual behaviors related to alcohol consumption. Prenatal viral infections are not a typical indicator of alcohol-related concerns.

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A nurse in a long-term care facility is assessing a client who has dementia. Which of the following findings should the nurse identify as a risk for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is assessing an older adult client for depression. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is screening a group of clients for potential mental health conditions. Which of the following questions should the nurse ask to determine a client's risk for alcohol use disorder?

Correct Answer is C

Explanation

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