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":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"A"}}
Explanation
Airborne precautions (Anticipated): Tuberculosis is an airborne disease, requiring negative pressure isolation, N95 respirators, and airborne precautions to prevent transmission.
Rifampin (Anticipated): A key first-line TB medication that inhibits bacterial RNA synthesis. It is part of the standard RIPE (Rifampin, Isoniazid, Pyrazinamide, Ethambutol) regimen.
Contact precautions (Contraindicated): TB does not spread via direct contact, so contact precautions (gloves, gowns) are unnecessary unless the client has open wounds with drainage.
Isoniazid (Anticipated): A primary anti-TB drug that inhibits mycolic acid synthesis, crucial for treating active and latent TB infections.
Monthly TB skin test for 1 year (Contraindicated): Once TB is diagnosed, routine Mantoux tests are unnecessary, as they will likely remain positive due to prior exposure.
Pyrazinamide (Anticipated): A bactericidal TB medication used in the intensive phase of treatment to shorten therapy duration.
Ethambutol (Anticipated): Used to prevent drug resistance in TB treatment. Regular eye exams are needed due to the risk of optic neuritis.
Correct Answer is ["B","D","E"]
Explanation
A) Mongolian spots: Mongolian spots are common in newborns of Asian, Hispanic, and African descent and are not specifically associated with fetal alcohol syndrome (FAS). These spots are bluish-gray or purple and typically fade over time, but they are not a manifestation of FAS.
B) Microcephaly: Microcephaly, which is an abnormally small head, is a common feature of fetal alcohol syndrome. This condition results from the effects of alcohol on the developing brain during pregnancy, leading to a smaller-than-normal head size.
C) Single palmar crease: A single palmar crease is a common finding in Down syndrome and can occur in other conditions as well, but it is not a hallmark feature of fetal alcohol syndrome. While it may occasionally be seen in infants with FAS, it is not one of the most common or defining characteristics.
D) Thin upper lip: A thin upper lip is one of the hallmark facial features of fetal alcohol syndrome. It is part of the characteristic "facial dysmorphology" seen in FAS, along with other features such as a smooth philtrum
E) Small eyes: Small eyes, or microphthalmia, are also a characteristic feature of fetal alcohol syndrome. This abnormal eye size, along with other facial abnormalities, is often seen in infants affected by FAS.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.