A nurse is collecting data from the family members of a client who has Alzheimer's disease. Which of the following findings should the nurse identify is the priority and requires immediate intervention?
Social withdrawal
Wandering outside at night
Difficulty articulating words
Inability to remember their partner's name
The Correct Answer is B
A) Social withdrawal: While social withdrawal can be a sign of depression or a worsening cognitive decline in clients with Alzheimer's disease, it does not immediately threaten the client's safety. It is important to monitor and address, but it is not the priority concern that requires immediate intervention.
B) Wandering outside at night: This is the priority issue and requires immediate intervention. Wandering, especially at night, poses a significant safety risk to clients with Alzheimer's disease. The client may become lost, disoriented, or fall, leading to injury. Immediate steps should be taken to ensure the environment is safe, such as installing locks or alarms on doors, and potentially seeking further evaluation or care interventions to manage this behavior.
C) Difficulty articulating words: Difficulty with speech or articulation can occur as part of Alzheimer's disease, especially in the later stages. While it can be distressing for the client and family, it does not present an immediate threat to the client's safety. This issue should be addressed as part of the overall care plan, but it is not as urgent as wandering.
D) Inability to remember their partner's name: Memory loss, including difficulty remembering names, is a common symptom of Alzheimer's disease. While it can be emotionally difficult for both the client and their family, it does not pose an immediate risk to the client’s safety or well-being. This symptom should be monitored, but it is not the top priority for immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Initiate droplet precautions: Respiratory syncytial virus (RSV) is primarily spread through contact with respiratory secretions, and droplet precautions are essential to prevent transmission. While RSV is commonly transmitted via direct contact or droplets, additional precautions like contact precautions may also be required, but droplet precautions should definitely be initiated as part of standard care to prevent the spread of the virus to others.
B) Monitor the preschooler’s urine for protein: Monitoring the urine for protein is not a standard action related to RSV. RSV is a respiratory virus, and its primary symptoms and complications involve the respiratory system, such as difficulty breathing, wheezing, or respiratory distress. There is no direct link between RSV and proteinuria, so this action is not necessary.
C) Administer fluconazole to the preschooler: Fluconazole is an antifungal medication, and it is not used to treat respiratory syncytial virus. RSV is a viral infection, so antiviral medications or supportive care like oxygen therapy, hydration, and possibly bronchodilators may be more appropriate. Fluconazole would not be appropriate for treating a viral infection like RSV.
D) Request an x-ray of the preschooler’s neck: An x-ray of the neck is generally not indicated for RSV unless there is a specific concern about airway obstruction or another condition like croup, which may present with symptoms similar to RSV. RSV primarily affects the lower respiratory tract, leading to symptoms like wheezing, cough, and difficulty breathing, not necessarily requiring a neck x-ray.
Correct Answer is D
Explanation
A) I have a difficult time getting my child to eat green vegetables: While it’s common for preschoolers to be selective about food, especially vegetables, this issue does not represent an immediate concern for the child’s health or development. This issue can often be addressed with strategies to encourage healthy eating, but it is not as urgent as other concerns.
B) My child continually asks me the same questions: Repetitive questioning is a normal part of preschool development, as children at this age are curious and often seek reassurance. It reflects their cognitive development as they try to understand the world around them. While it may be tiring for the guardian, it is not an immediate concern.
C) My child still wets the bed at least two times per week: Bedwetting (enuresis) is common among preschool-aged children, and many children do not gain full bladder control until after age 5. This issue is typically addressed if it continues past the age of 5, but it is not a priority at this time.
D) I have noticed that my child is withdrawn since we switched day care providers: This statement indicates a potential emotional or behavioral issue that requires immediate attention. Changes in behavior, such as withdrawal, can be a sign of stress, anxiety, or difficulty adjusting to a new environment. The nurse should prioritize this concern, as it may indicate that the child is having difficulty coping with the transition and may need additional support or evaluation. Addressing emotional well-being is a priority for the nurse.
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