A nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the following manifestations of dementia should the nurse include in the teaching?

Temporary, reversible loss of brain function

Forgetfulness gradually progressing to disorientation

Hyper vigilant behaviors

Sleeping more during the day than nighttime

Answer and Explanation

The Correct Answer is B

A. Primary dementia is not characterized by temporary or reversible loss of brain function; it typically involves progressive and irreversible changes.
B. Forgetfulness that gradually progresses to disorientation is a common manifestation of primary dementia, indicating cognitive decline.
C. Hyper vigilant behaviors are not typical of dementia; instead, individuals may exhibit confusion or disorientation.
D. Sleeping more during the day than nighttime is not a specific manifestation of primary dementia and could be attributed to other factors, including other medical conditions or medications.

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Correct Answer is A

Explanation

A. Autonomic dysreflexia is often triggered by a noxious stimulus, such as bladder distention. Preventing bladder distention by ensuring regular bladder emptying can help prevent the condition.
B. Elevating the client's head is a response to autonomic dysreflexia but does not prevent it from occurring.
C. Providing analgesia for headaches addresses a symptom of autonomic dysreflexia but does not prevent it.
D. Monitoring for elevated blood pressure is important in detecting autonomic dysreflexia once it has started, but it does not prevent it.

A. Document the findings and continue with the visit. B. Notify the RN case manager of the change in status. C. Reinforce the importance of daily weights. D. Ensure the client has been taking their prescribed diuretic.

Correct Answer is B

Explanation

A. Documenting the findings and continuing the visit does not address the potential seriousness of the weight gain and edema in a patient with heart failure. It is important to act promptly on such findings.

B. Notifying the RN case manager of the change in status is essential because a weight gain of this magnitude, along with generalized edema, may indicate worsening heart failure. This requires a timely assessment and possible adjustment of the treatment plan, including medication and fluid management.

C. While reinforcing the importance of daily weights is beneficial for long-term management, it is not an immediate intervention for the acute change in the patient’s condition.

D. Ensuring the client has been taking their prescribed diuretic is important, but the nurse should first communicate the significant changes to the RN case manager for further evaluation and intervention, as this might require a medication review or adjustment.

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A nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the following manifestations of dementia should the nurse include in the teaching?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?

Correct Answer is A

Explanation

A home health nurse is collecting data from a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?

Correct Answer is B

Explanation

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