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 B
Explanation
A.Pinpoint pupils are more commonly associated with opioid intoxication or damage to the pons rather than increased intracranial pressure (ICP). Increased ICP typically causes pupils to become dilated and sluggish or nonreactive to light
B.Irritability can be an early sign of increased intracranial pressure. As pressure within the skull rises, it can affect the brain's ability to function normally, leading to changes in behavior such as restlessness, agitation, or irritability.
C.Pallor is not directly associated with increased intracranial pressure. It might indicate other issues such as anemia or poor circulation, but it is not a specific sign of increased ICP.
D. Increased intracranial pressure typically leads to hypertension (increased blood pressure) as part of the Cushing's triad, which includes hypertension, bradycardia, and irregular respirations. Decreased blood pressure would not be a typical finding associated with increased ICP.
Correct Answer is D
Explanation
A. Maintain low-level lights in common areas.Low-level lighting can increase confusion and the risk of falls, especially for clients with memory loss. It is important to have adequate lighting to promote a safe environment and help with orientation. Well-lit areas can reduce disorientation and anxiety in clients who are confused or have memory issues.
B. Give the client several meal options at lunchtime. For clients with memory loss and confusion, it is better to provide simple choices or pre-selected meals to reduce decision-making stress and confusion.
C. Confront the client regarding inappropriate behavior.Confronting a client with memory loss or confusion about inappropriate behavior can increase agitation, anxiety, and defensive reactions.
D. Use symbols in the communal room signage.Symbols and pictures can help clients with memory loss navigate their environment more easily because they may have difficulty reading or comprehending written language. Visual cues such as symbols in signage can improve orientation and independence, helping the client feel more comfortable in their surroundings.
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