A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?
Memory loss that disrupts ADLs
Catatonia
Illusions
Pressured speech
The Correct Answer is A
Dementia is a condition characterized by a decline in cognitive function that affects a person's ability to perform activities of daily living (ADLs). Memory loss is a common symptom of dementia, particularly in the early stages. Memory loss can disrupt a person's ability to carry out tasks they were previously able to do independently, such as dressing, bathing, and eating. Therefore, option A is the correct answer.
Option b, catatonia, is a condition characterized by a lack of movement or activity, which is not typically associated with dementia.
Option c, illusions, involve a misinterpretation of sensory information and may occur in some forms of dementia but are not a defining feature.
Option d, pressured speech, is a symptom commonly associated with mania or bipolar disorder but is not typically seen in dementia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Waiting 1 minute between suctioning attempts allows the client to recover and ensures that the procedure is not overly invasive. It also helps to prevent the client from becoming hypoxic.
The distance that the nasopharyngeal catheter should be inserted varies from person to person and therefore 10 cm is not standard.
During nasopharyngeal suctioning, the nurse should apply suction intermittently while withdrawing the catheter, not during insertion. Applying suction during insertion can cause tissue damage and increase the risk of trauma.
The nurse should also apply intermittent suction for no longer than 15 seconds to prevent hypoxia and damage to the mucosal lining. Suctioning for an extended period can cause discomfort and harm to the client.
Correct Answer is A
Explanation
a. Verify the medication three times with the medication administration record.
When administering oral medications, the nurse should verify the medication three times with the medication administration record to ensure that the correct medication is being given to the correct client at the correct time. This is known as the "three checks" and is an important step in preventing medication errors.
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