A nurse is caring for a client who has Alzheimer's disease.
Which of the following findings should the nurse expect?
Altered level of consciousness.
Rapid mood swings.
Excessive motor activity.
Failure to recognize familiar objects.
The Correct Answer is D
Choice A rationale:
An altered level of consciousness is a common finding in clients with Alzheimer's disease. This may range from mild confusion to severe cognitive impairment. It is caused by the degeneration of brain cells and affects memory, thinking, and behavior.
Choice B rationale:
Rapid mood swings are not specific to Alzheimer's disease. While mood changes can occur, they are not typically characterized by rapid swings. Mood disturbances may include depression, apathy, or irritability, but these symptoms are not unique to Alzheimer's disease.
Choice C rationale:
Excessive motor activity is not a typical finding in clients with Alzheimer's disease. Instead, clients often experience a decline in motor skills and coordination as the disease progresses. Restlessness or agitation might occur, but excessive motor activity is not a characteristic feature.
Choice D rationale:
Failure to recognize familiar objects, people, or places is a common symptom of Alzheimer's disease. This is due to the damage and loss of nerve cells in the brain. As the disease advances, clients may have difficulty recognizing even close family members or their own reflection in the mirror.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Providing a verbal report of the client's condition to the paramedic performing the transfer violates the client's confidentiality. Protected health information should not be disclosed verbally to individuals who do not have a need to know. Confidentiality must be maintained during all stages of care, including transfers.
Choice B rationale:
Faxing the client's name and identifiable information to the rehabilitation facility is not a secure method of transmitting sensitive health information. Faxed documents can be intercepted, compromising the client's confidentiality. Secure electronic methods or encrypted communication should be used for transmitting such information.
Choice C rationale:
Emailing the client's health information to the facility in an unencrypted file is also insecure and violates the client's confidentiality. Unencrypted emails can be intercepted and read by unauthorized individuals. Protected health information should be transmitted using secure, encrypted methods to maintain confidentiality.
Choice D rationale:
Discussing the client's response to the transfer with another staff nurse is inappropriate and breaches confidentiality. Sharing patient information, even within the healthcare team, should only be done on a need-to-know basis and in a secure, private setting.
Correct Answer is A
Explanation
Question 1: The correct answer is Choice A - Stabilize the tube by taping it to the infant’s cheek.
Choice A Rationale: Stabilizing the nasogastric tube by taping it to the infant's cheek is crucial to prevent displacement, which could lead to complications such as misplacement into the respiratory tract or discomfort for the infant. Proper securing ensures the tube remains in the intended position, facilitating the safe and effective delivery of nutrients. This action aligns with standard nursing practices to promote patient safety and comfort during enteral feedings.
Choice B Rationale: Option B suggests positioning the infant in a supine position during feedings, which is incorrect. Placing the infant in a supine position increases the risk of aspiration due to the potential for reflux. Instead, the infant should be positioned upright or semi-upright with the head elevated to minimize the risk of regurgitation and aspiration.
Choice C Rationale: Aspiration of residual fluid from the infant's stomach and discarding it (Option C) is not recommended practice. Aspirated gastric contents should be measured and assessed for volume and color to evaluate gastrointestinal function and potential complications. Discarding the aspirate without evaluation could lead to the oversight of important clinical indicators or abnormalities in the infant's condition.
Choice D Rationale: Microwaving the infant's formula to a temperature of 41°C (105.8°F) (Option D) is an incorrect practice. Heating formula in a microwave can result in uneven temperature distribution, creating hot spots that may cause burns to the infant's delicate oral mucosa or esophagus. The preferred method for warming formula is to use a water bath or bottle warmer to achieve a consistent temperature close to body temperature (around 37°C or 98.6°F).
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