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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The correct answer is choiceA. Lift the penis so that it is perpendicular to the client’s body.

Choice A rationale:

Lifting the penis so that it is perpendicular to the client’s body straightens the urethra, making it easier to insert the catheter without causing trauma.

Choice B rationale:

While cleansing the tip of the penis in a circular motion is important for maintaining aseptic technique, it is not the specific action that facilitates the insertion of the catheter.

Choice C rationale:

Picking up the catheter 13 cm (5 in) from its tip is not a standard practice.The nurse should hold the catheter closer to the tip to maintain control and ensure accurate insertion.

Choice D rationale:

Inflating the catheter balloon before insertion can cause trauma to the urethra and is not recommended.The balloon should only be inflated once the catheter is correctly positioned in the bladder.

A. A client who received a Mantoux test 48 hr ago and has an induration. B. A client who is taking warfarin and has an INR of 1.8. C. A client who is scheduled for a colonoscopy and is taking sodium phosphate. D. A client who is taking bumetanide and has a potassium level of 3.6 mEq/L.

Correct Answer is B

Explanation

Choice A rationale:

A client who received a Mantoux test 48 hr ago and has an induration does not require immediate follow-up care. An induration at the injection site indicates a positive reaction, but further evaluation and management are necessary, not urgent.

Choice B rationale:

A client taking warfarin with an INR of 1.8 requires follow-up care. The normal range for INR in a client taking warfarin is usually 2.0 to 3.0. An INR of 1.8 suggests inadequate anticoagulation, putting the client at risk of thromboembolic events. Dose adjustment or other interventions are needed to bring the INR within the therapeutic range.

Choice C rationale:

A client scheduled for a colonoscopy and taking sodium phosphate does not necessarily require immediate follow-up care. However, sodium phosphate can cause electrolyte imbalances, so monitoring for any signs of electrolyte disturbances is essential, but it does not mandate urgent intervention.

Choice D rationale:

A client taking bumetanide with a potassium level of 3.6 mEq/L requires follow-up care. The normal range for potassium is typically 3.5 to 5.0 mEq/L. A potassium level below the normal range (hypokalemia) can lead to cardiac arrhythmias and muscle weakness. The client may need potassium supplements or dietary adjustments to correct the imbalance.

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A nurse is caring for a client who has Alzheimer's disease.Which of the following findings should the nurse expect?

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Correct Answer is B

Explanation

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A nurse is caring for a client who has Alzheimer's disease.
Which of the following findings should the nurse expect?