A nurse is caring for a 76-year-old female client who experienced a fall.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to collect data about the client's progress.
The Correct Answer is []
Condition: Alzheimer's disease.
2 actions:
Use symbols rather than written signs for directions,
Anticipate a prescription for donepezil.
2 parameters:
Presence of agnosia,
Ability to complete familiar tasks.
Rationale for correct condition: Alzheimer's disease explains the client's confusion, disorientation, and difficulty with familiar tasks. The client's inability to recall their home address and confusion with objects (call light and washcloth) aligns with cognitive decline. Alzheimer's disease often presents with memory loss and impaired judgment. The client's symptoms are progressive and not episodic. The overall presentation fits the profile of Alzheimer's disease.
Rationale for actions: Using symbols helps clients with Alzheimer's navigate and recognize their environment more easily. Symbols are easier to interpret than written signs. Donepezil can help manage symptoms by increasing acetylcholine levels. It supports cognitive function in Alzheimer's patients. Determining the date of the last eye examination is less relevant. Eye exams do not address cognitive decline directly. Duloxetine treats depression, not cognitive impairment. Monitoring agnosia tracks the client's ability to recognize objects. Completing familiar tasks assesses cognitive function. Night vision is less critical in cognitive assessment. Oxygen saturation is stable and not related to cognitive issues.
Rationale for parameters: Presence of agnosia helps identify progression of Alzheimer's. Monitoring familiar tasks assesses daily functioning and cognitive decline. Night vision is not directly related to cognitive assessment. Oxygen saturation is not affected by Alzheimer's. Cognitive tasks and object recognition are more relevant in this context.
Rationale for incorrect conditions: Expected aging process does not explain the severity of symptoms. Major depressive disorder presents differently with mood-related symptoms. Delirium is acute and reversible, not fitting the chronic, progressive nature of Alzheimer's disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Placing a lock at the top of doors helps prevent the client from wandering outside, ensuring safety.
Choice B rationale
Using light restraints is not recommended due to ethical concerns and potential harm.
Choice C rationale
Administering antianxiety medication should not be the first strategy due to potential side effects and over-medication.
Choice D rationale
Encouraging napping during the day may worsen nighttime wakefulness and wandering.
Correct Answer is A
Explanation
Choice A rationale
Acknowledging the client's fear and providing reassurance without confirming the hallucination helps build trust and reduce anxiety.
Choice B rationale
Correcting the client by stating it is a syringe, not a snake, dismisses their fear and can increase distress.
Choice C rationale
Emphasizing the provider's requirement for the blood specimen does not address the client's fear and can worsen anxiety.
Choice D rationale
Telling the client they are mistaken dismisses their hallucination and can increase their distress and mistrust.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.