A nurse is planning care for a client who has dementia and lives at home. Which of the following physiological changes should the nurse educate the client and family to monitor?
Weight loss
Decreased mobility
Increased physical activity
Unkempt appearance
Constipation
Correct Answer : A,B,C,D,E
A. Weight loss:
Weight loss can occur in individuals with dementia due to various factors, including decreased appetite, difficulty eating or swallowing, and increased energy expenditure.
Monitoring weight regularly can help detect changes in nutritional status and identify potential health concerns, such as malnutrition or dehydration.
B. Decreased mobility:
Individuals with dementia may experience a decline in mobility and functional abilities as the disease progresses.
Monitoring changes in mobility, such as difficulty walking, transferring, or performing activities of daily living, is important for assessing functional decline and implementing appropriate interventions to maintain mobility and prevent complications such as falls.
C. Increased physical activity:
While dementia can lead to decreased physical activity in some individuals, others may exhibit increased restlessness or wandering behaviors.
Monitoring changes in physical activity levels can help identify agitation, restlessness, or wandering behaviors that may require intervention to ensure the safety and well-being of the individual with dementia.
D. Unkempt appearance:
Individuals with dementia may neglect personal hygiene and grooming tasks, leading to an unkempt appearance.
Monitoring changes in appearance, such as poor personal hygiene, disheveled clothing, or neglect of grooming habits, can indicate difficulties with self-care and may necessitate assistance or supervision to maintain hygiene and appearance.
E. Constipation:
Constipation is a common gastrointestinal symptom in individuals with dementia, often due to factors such as reduced fluid intake, decreased physical activity, and side effects of medications.
Monitoring bowel habits and addressing constipation promptly can help prevent discomfort, complications such as fecal impaction, and maintain overall gastrointestinal health in individuals with dementia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Tonometer intraocular pressure reading 8 mm Hg (Option A): A low intraocular pressure reading may indicate a detached retina. In a detached retina, the vitreous humor (gel-like substance in the eye) may leak into the space behind the retina, causing a decrease in intraocular pressure. However, it's important to note that intraocular pressure alone cannot definitively diagnose a detached retina, and further diagnostic tests, such as a dilated eye examination or retinal imaging, would be needed for confirmation.
Smooth retina edges identified on slit-lamp biomicroscope examination (Option B): In the case of a detached retina, the edges of the retina may appear irregular or undulating rather than smooth. This irregularity is often observed during a dilated eye examination rather than with a slit-lamp biomicroscope.
Visual acuity of 20/20 using the Snellen eye chart (Option C): Visual acuity may be affected in a detached retina, depending on the extent and location of the detachment. However, visual acuity alone cannot confirm a detached retina, as other factors such as refractive errors or cataracts can also affect visual acuity.
Lens and cornea appear intact during ophthalmoscope exam (Option D): While a detached retina may be visualized during an ophthalmoscope examination as a gray or whitish area behind the lens, the appearance of the lens and cornea being intact does not definitively diagnose a detached retina. A thorough dilated eye examination by an ophthalmologist is necessary for accurate diagnosis.
Correct Answer is B
Explanation
A. "Your heart condition is caused by excessive stretching of the ventricles": This statement is incorrect. Excessive stretching of the ventricles typically occurs in dilated cardiomyopathy, not restrictive cardiomyopathy (RCM). In RCM, the primary issue is not excessive stretching but rather stiffening of the ventricular walls.
B. "Your heart condition is caused from stiffening of the walls of the ventricles": This statement is correct. Restrictive cardiomyopathy (RCM) is characterized by abnormal stiffening (fibrosis) of the ventricular walls, which impairs the heart's ability to fill properly during the diastolic phase of the cardiac cycle. This stiffening restricts the heart's ability to relax and fill with blood efficiently.
C. "Your heart condition is caused by thickening of the ventricular walls and septum": This statement describes hypertrophic cardiomyopathy (HCM), not restrictive cardiomyopathy (RCM). In HCM, there is abnormal thickening of the ventricular walls and septum, leading to impaired filling of the ventricles and potential obstruction of blood flow out of the heart.
D. "Your heart condition is caused when the ventricular tissue becomes fibrous and fatty": This statement describes arrhythmogenic right ventricular cardiomyopathy (ARVC), not restrictive cardiomyopathy (RCM). ARVC is characterized by replacement of myocardial tissue with fibrous and fatty tissue, primarily affecting the right ventricle.
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