A nurse is admitting a client who has dementia related to a traumatic brain injury. Which of the following findings should indicate to the nurse that the client's condition is worsening?
Visual field cuts
Decreased CD4 counts
Shuffling gait
Chorea
The Correct Answer is C
C. Dementia related to a traumatic brain injury can result in a variety of cognitive and physical impairments. A shuffling gait, characterized by short steps with feet barely leaving the ground, is often associated with Parkinsonian symptoms, which can occur in advanced stages of dementia or as the condition progresses. Therefore, a shuffling gait would indicate worsening of the client's condition.
A. While visual disturbance can occur in individuals with dementia, visual field cuts alone may not necessarily indicate worsening of the condition unless they are accompanied by other concerning symptoms.
B. CD4 counts are a measure of immune system function, particularly in relation to HIV/AIDS. Decreased CD4 counts are not typically associated with dementia related to traumatic brain injury and would not be a relevant finding in this context.
D. Chorea is not a common feature of dementia related to traumatic brain injury. The presence of chorea may indicate a different underlying neurological condition or complication
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A Offering information about support groups for parents can provide the client with access to peer support, education, and resources to help them navigate the challenges of parenting while dealing with their mental health condition. This approach supports the client's autonomy and emphasizes a strengths-based perspective, promoting resilience and well-being for both the client and their children.
B. This option may not be appropriate without further assessment of the client's ability to care for their children.
C. This option should be considered only if there are significant concerns about the safety and welfare of the children, such as neglect or abuse, which cannot be addressed through other means.
D. Encouraging the children to visit the psychiatric unit may not be appropriate, as it may be overwhelming or distressing for them.
Correct Answer is A
Explanation
A. When a nurse observes illegal or unethical behavior, such as stealing narcotics, it is their ethical and legal responsibility to report the incident promptly to the appropriate authorities.
B. While it's important to encourage the coworker to seek treatment for their substance abuse issue, withholding reporting of the incident compromises patient safety and violates organizational policies and legal obligations. It's essential to report the incident regardless of the coworker's actions afterward.
C. Reporting the incident to other RNs on the shift may not be sufficient action to address the seriousness of the situation. While it's important for colleagues to be aware of potential risks to patient safety, the primary responsibility lies with reporting the incident to the appropriate authorities within the organization.
D. Agreeing not to report the incident in exchange for the coworker promising to report themselves to the supervisor is not an appropriate course of action. It's essential to follow established reporting protocols and ensure that the incident is documented and addressed through the appropriate channels to protect patient safety and uphold professional standards.
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