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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["B","C","E"]

Explanation

A. Chronic health condition: The client has a history of Parkinson’s disease and anxiety, which are relevant but not immediate concerns. Chronic conditions require long-term management rather than urgent intervention.
B. Current level of consciousness: The client is restless and not following commands, which may indicate hypoxia, worsening infection, or sepsis. A change in mental status is a critical finding requiring immediate evaluation.
C. Oxygen saturation level: The oxygen saturation is 89% on room air, which is below the normal range (≥95%). This suggests respiratory compromise, likely due to pneumonia, requiring urgent oxygen support.
D. Heart rate: The client has a heart rate of 104/min, which is mildly elevated and expected due to fever and respiratory distress. However, it is not the most critical concern compared to respiratory distress and altered mental status.
E. Respiratory rate: The respiratory rate is 30/min, indicating tachypnea and increased work of breathing, suggesting respiratory distress or impending respiratory failure. This requires immediate intervention.
F. Tremors: Tremors are a common finding in Parkinson’s disease and do not require immediate intervention.

A. Insert an oral airway into the client’s mouth B. Measure the duration of the seizure. C. Lower the side rails of the bed when the seizure begins. D. Restrain the client's arms and legs to prevent injury.

Correct Answer is D

Explanation

A. Insert an oral airway into the client’s mouth:Attempting to insert any object into the mouth during a seizure risks airway obstruction, dental injury, or aspiration of oral secretions or broken teeth. The jaw is typically clenched, making insertion unsafe and impractical.

B. Measure the duration of the seizure:While timing the seizure is important for documentation and determining if status epilepticus occurs, it should not take precedence over immediate physical safety measures. Restraint to prevent injury must occur first.

C. Lower the side rails of the bed when the seizure begins:Lowering the side rails increases the risk of the client falling from the bed. Instead, the bed rails should remain raised and padded (if possible) to create a contained, safe environment.

D. Restrain the client's arms and legs to prevent injury:Gentle but firm restraint of the extremities reduces the risk of the client striking themselves against hard surfaces (e.g., bed rails, walls) or experiencing dislocations, fractures, or self-inflicted trauma. Restraint should be applied cautiously to avoid excessive force, but it is necessary to maintain physical control during the seizure’s intense muscular contractions.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of an older adult client who was admitted Select the 3 findings that require immediate follow-up

Correct Answer is ["B","C","E"]

Explanation

A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following action should the nurse take?

Correct Answer is D

Explanation

A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?

A nurse is collecting data from a client who has been taking medroxyprogesterone for 6 months. Which of the following statements by the client should the nurse identify as the priority to report?

A nurse is reinforcing teaching with a client about reducing dietary caffeine intake. The nurse should remind the client that 240 mL (8 oz) of which of the following beverages contains the least amount of caffeine?

A nurse is reviewing laboratory results for a client who has metabolic alkalosis. Which of the following blood gas values should the nurse expect?

A nurse is caring for a client who is to begin chemotherapy. The client asks the nurse about managing hair loss. Which of the following reponses should the nurse make?

A nurse is providing change-of-shift report for a client. Which of the following information should the nurse include in the report?

A nurse is assisting with the care of a client who is receiving a spinal epidural to treat a herniated disc. Which of the following findings should the nurse identify as an indicator of unrelieved pain?

A nurse is transcribing a client’s prescription for erythromycin 500mg four times per day. Which of the following information should the nurse clarify with the provider?