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 B
Explanation
A) Patient Health Questionnaire - 9:
The Patient Health Questionnaire-9 (PHQ-9) is a screening tool used to assess the severity of depression in a client. It is not specific to detecting tardive dyskinesia, which is a movement disorder caused by long-term use of antipsychotic medications. Therefore, this tool is not appropriate for assessing tardive dyskinesia.
B) Abnormal Involuntary Movement Scale:
The Abnormal Involuntary Movement Scale (AIMS) is the correct tool to screen for tardive dyskinesia. It is specifically designed to assess involuntary movements, such as those seen in tardive dyskinesia, which is a common side effect of long-term use of antipsychotic medications. The AIMS evaluates the presence and severity of abnormal movements, making it the most appropriate tool for this purpose.
C) Mental Status Examination:
The Mental Status Examination (MSE) is a broad assessment used to evaluate a client’s cognitive and emotional functioning. It includes aspects such as appearance, behavior, mood, thoughts, and perception but does not specifically assess for movement disorders like tardive dyskinesia. While it can provide useful information about a client's mental state, it is not focused on detecting motor side effects of antipsychotic medications.
D) Brief Psychiatric Rating Scale:
The Brief Psychiatric Rating Scale (BPRS) is used to assess the severity of psychiatric symptoms, including delusions, hallucinations, and mood disturbances, primarily in individuals with schizophrenia or other psychiatric disorders. It does not specifically assess for tardive dyskinesia, so it is not the most appropriate screening tool for identifying this condition.
Correct Answer is D
Explanation
A) Rubella titer nonimmune: A nonimmune rubella titer indicates that the client is not immune to rubella, which is a common finding in many pregnant women. However, rubella vaccination is not given during pregnancy because the vaccine is a live virus. The client will typically be vaccinated postpartum. Follow-up would be required, but it is not an urgent concern during the pregnancy itself.
B) Negative varicella titer: A negative varicella titer means the client is not immune to chickenpox, which is a concern because varicella can cause serious complications during pregnancy. However, similar to rubella, the varicella vaccine is contraindicated during pregnancy, and vaccination would be given postpartum. This requires follow-up after delivery but does not require urgent intervention during the pregnancy.
C) Positive Rh factor: The Rh factor is a blood type characteristic, but what is typically more concerning is the Rh incompatibility, which occurs when a Rh-negative mother carries a Rh-positive baby. A positive Rh factor is not a problem for the client themselves but could be important if the father is Rh-positive. If there is concern for Rh incompatibility, the nurse would monitor for the development of Rh sensitization and administer Rh immunoglobulin (RhoGAM) if needed. This does not require urgent intervention unless Rh incompatibility is confirmed.
D) Positive serologic test for syphilis: A positive test for syphilis requires immediate follow-up intervention. Syphilis is a sexually transmitted infection that can cause serious complications during pregnancy, including miscarriage, stillbirth, preterm birth, and congenital syphilis. Treatment with penicillin is recommended to prevent transmission to the baby and to treat the infection in the mother. A positive serologic test for syphilis warrants prompt intervention.
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