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 D
Explanation
A) "I should eat a high fat diet for several weeks": After a laparoscopic cholecystectomy, the client is typically advised to avoid high-fat foods for a period of time as the body adjusts to the absence of the gallbladder. High-fat foods can trigger discomfort, nausea, or diarrhea. Therefore, recommending a high-fat diet is not appropriate post-surgery.
B) "I should expect to have diarrhea until my diet changes": Diarrhea is a possible side effect following gallbladder removal, particularly due to the changes in bile flow. However, the client should not expect diarrhea indefinitely. Over time, the digestive system adjusts, and with dietary modifications, diarrhea often resolves. The client should not assume this will persist unless directed by the healthcare provider.
C) "I should expect to have nausea for several days": Nausea is not typically expected to last for several days following a laparoscopic cholecystectomy. While mild nausea can occur shortly after surgery, it should subside within a short time. If nausea persists beyond this period, the client should notify their healthcare provider for further evaluation.
D) "I should leave my steri-strips on until they fall off.": Steri-strips are used to help close the incision site and should remain in place until they naturally fall off, which usually occurs within 7–10 days after surgery. This statement indicates that the client understands the proper care for their incision site. It is important not to remove them prematurely to avoid disrupting the healing process.
Correct Answer is B
Explanation
A) Encourage the family to be with the child during mealtimes: While family support during mealtimes can be helpful, it is not the first priority in this situation. The most important step is to understand the child’s dietary habits and challenges in order to create a more targeted and effective approach to addressing the poor dietary intake.
B) Obtain the child’s dietary history: The first step should be to gather information about the child’s dietary history. Understanding what the child is eating, how often, and any potential barriers to proper nutrition (e.g., food preferences, allergies, or cultural practices) is crucial for identifying the root cause of the poor dietary intake. This information will guide the nurse in making appropriate recommendations for improving the child's nutrition.
C) Instruct the family to praise the child when they eat: While positive reinforcement can be a useful strategy, it is not the first step in addressing poor dietary intake. The nurse needs to assess the child’s dietary habits and any possible issues before recommending specific behavioral strategies.
D) Offer the child nutritious snacks between meals: Offering nutritious snacks is a good strategy for improving a child’s nutrition, but it should come after gathering a clear understanding of the child’s eating habits. Without knowing the child’s preferences and needs, it’s better to first assess and identify the cause of the poor intake before recommending snacks.
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