A nurse is assessing a client for manifestations of mild Alzheimer's disease. Which of the following findings should the nurse expect as an early indication of the disease?

Difficulty maintaining personal hygiene.

Difficulty handling finances.

Difficulty remembering names of new friends.

Difficulty driving to and from familiar places.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Difficulty maintaining personal hygiene is not typically an early indication of mild Alzheimer's disease. In the early stages, individuals can still manage personal hygiene.

Choice B rationale:

Difficulty handling finances may occur in the later stages of Alzheimer's disease, but it is not an early indication. In the early stages, the person might still manage financial matters.

Choice C rationale:

Difficulty remembering the names of new friends is a common early sign of mild Alzheimer's disease. It reflects the impairment of short-term memory that often occurs in the early stages of the disease.

Choice D rationale:

Difficulty driving to and from familiar places is more likely to be a mid-to-late-stage symptom of Alzheimer's disease. In the early stages, individuals might still drive familiar routes with minimal difficulty.

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Correct Answer is D

Explanation

Choice A rationale:
A warm left leg is a normal finding and does not require immediate intervention. Warmth indicates adequate circulation to the limb.
Choice B rationale:
A pedal pulse strength of 2 in the left leg indicates diminished pulse but does not require immediate intervention. The nurse should continue to monitor the pulse and report any significant changes to the healthcare provider.
Choice C rationale:
The client's report of pain in the foot of the left leg is an expected finding due to the fractured left femur. Pain is a subjective symptom, and the nurse should address the client's pain appropriately but not intervene immediately based on this finding.
Choice D rationale:
This is the correct choice. A capillary refill time of 3 seconds in the left foot suggests impaired circulation, which could be indicative of compartment syndrome or other circulation-related issues. The nurse should intervene immediately by notifying the healthcare provider to prevent further complications.

A. Administer furosemide. B. Weigh the client weekly. C. Offer the client a high-sodium diet. D. Administer heparin. E. None F. None

Correct Answer is A

Explanation

Answer: A. Administer furosemide.

Rationales

A. Administer furosemide.
Furosemide, a loop diuretic, helps reduce fluid overload by promoting urinary excretion of sodium and water. In a client with cirrhosis and ascites, it decreases abdominal distention, eases breathing by reducing pressure on the diaphragm, and prevents complications related to severe fluid accumulation.

B. Weigh the client weekly.
Weekly weights would not provide sufficient monitoring for a client with ascites, since fluid retention can change rapidly within hours or days. Daily weights are necessary to detect subtle increases in fluid status and to evaluate the effectiveness of treatment.

C. Offer the client a high-sodium diet.
A high-sodium diet would worsen fluid retention and ascites, as sodium promotes water retention. Instead, a low-sodium diet is indicated to limit further fluid buildup in the peritoneal cavity.

D. Administer heparin.
Heparin is not a standard intervention for cirrhosis with ascites. Because the diseased liver produces fewer clotting factors, clients are already at risk for bleeding, and anticoagulant therapy would heighten this risk without addressing the underlying problem of fluid accumulation.

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A nurse is assessing a client for manifestations of mild Alzheimer's disease. Which of the following findings should the nurse expect as an early indication of the disease?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a neurovascular assessment on a client who has a fractured left femur. For which of the following findings should the nurse intervene immediately?

Correct Answer is D

Explanation

A nurse is planning care for a client who has long-term liver cirrhosis and a new diagnosis of abdominal ascites. Which of the following interventions should the nurse include in the plan of care to prevent complications?

Correct Answer is A

Explanation

Answer: A. Administer furosemide.

Rationales

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