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.

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Correct Answer is C

Explanation

A) "I get nervous when I'm in a large group": Social anxiety or nervousness in large groups is common, especially during adolescence. While it can indicate discomfort in social situations, it is not necessarily a warning sign of suicidal ideation.

B) "My partner and I had our first argument last night": Relationship conflicts are a normal part of adolescent development, and although they can cause emotional distress, a single argument does not typically indicate a risk for suicide. It’s important to assess the client’s overall emotional state and coping mechanisms, but this statement alone does not suggest suicidal thoughts.

C) "I am not interested in anything anymore.": This statement is a red flag for depression and potential suicidal ideation. A loss of interest or pleasure in activities that were once enjoyable (anhedonia) is a core symptom of depression, which can be a significant risk factor for suicide. This warrants further exploration and immediate attention from the nurse.

D) "I'm not sleeping much because of all the homework I have.": While lack of sleep can be a concern and may affect an adolescent’s overall health and well-being, it is more likely related to stress or academic pressure rather than suicidal thoughts. Sleep disturbances in adolescents are common, particularly when facing high academic expectations, but this is not an immediate sign of suicide risk.

A. Believes the death is punishment for bad behavior B. Recognizes the parent will never wake up C. Understands that everyone dies eventually D. Expresses curiosity about the funeral service

Correct Answer is A

Explanation

A) Believes the death is punishment for bad behavior: Preschoolers, typically ages 3 to 5, often engage in magical thinking and may believe that death is a result of their own actions or bad behavior. They may see death as a punishment for something they did wrong, as they have difficulty understanding the permanence and inevitability of death. This egocentric thinking is typical for their developmental stage.

B) Recognizes the parent will never wake up: Preschoolers may not yet fully comprehend the permanence of death. They may think the deceased parent will eventually wake up or return. This belief reflects their limited understanding of death, which they may view as reversible or temporary, especially if they haven't encountered death before.

C) Understands that everyone dies eventually: Preschoolers do not generally have the cognitive ability to grasp the concept that everyone dies eventually. This understanding develops later, typically during the concrete operational stage of development (around age 7 or 8), when children begin to understand death as permanent and universal.

D) Expresses curiosity about the funeral service: While some preschoolers may express curiosity about events like a funeral, it is more likely that their curiosity would be centered on simple, tangible aspects of death (such as asking questions about where the person went or what happens to their body) rather than the ceremony itself. At this stage, children may not fully understand the cultural or symbolic meanings of a funeral service.

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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?

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