A nurse is teaching a client who has peripheral venous disease about management of symptoms. Which of the following client statements indicates to the nurse an understanding of the teaching?

A. Assess palmar reflex. Assessing the palmar reflex helps evaluate the integrity of the nervous system, particularly in response to tactile stimuli. In clients with severe TBI, abnormal reflexes may indicate neurological impairment and guide further assessment and intervention.

B. Assess for cough reflex. Assessing the cough reflex is important for evaluating airway protection and the risk of aspiration, especially in clients with reduced consciousness level due to TBI.

C. Assess the ability to follow simple commands. Assessing the client's ability to follow simple commands provides valuable information about their level of consciousness and cognitive function. It helps determine the extent of neurological impairment and guides the plan of care, including interventions for communication and cognitive deficits.

D. Assess for Cushing's Triad. Cushing's Triad, characterized by hypertension, bradycardia, and irregular respirations, may occur as a late sign of increased intracranial pressure (ICP) in clients with severe TBI. Monitoring for Cushing's Triad is crucial for early recognition of elevated ICP and prompt intervention to prevent further neurological damage.

E. Assess for abnormal posturing. Assessing for abnormal posturing, such as decerebrate or decorticate posturing, helps evaluate neurological function and localize brain injury in clients with TBI. Abnormal posturing indicates severe brain damage and may guide decisions regarding treatment and prognostication.

A. Relocation stress syndrome: Relocation stress syndrome refers to the physical and psychological symptoms experienced by individuals when they are moved from one environment to another, such as transitioning to a new residence or healthcare facility. While relocation stress syndrome can cause agitation and confusion in individuals with Alzheimer's disease, the scenario provided does not indicate a recent relocation.

B. Wandering: Wandering is a common behavior observed in individuals with dementia, where they aimlessly roam or wander in their environment. While wandering may be associated with agitation and restlessness, the scenario does not describe the client physically moving around or attempting to leave their home.

C. Sundowning: Sundowning refers to a phenomenon commonly observed in individuals with Alzheimer's disease or other forms of dementia, where they experience increased agitation, confusion, and restlessness in the late afternoon or early evening hours. Sundowning behaviors can include pacing, agitation, anxiety, irritability, confusion, and difficulty sleeping. The exact cause of sundowning is not fully understood but may be related to factors such as fatigue, sensory overload, hormonal imbalances, or disruptions in the sleep-wake cycle. Managing sundowning behaviors often involves creating a calming environment, maintaining a consistent daily routine, minimizing stimuli in the evening, and providing reassurance and comfort to the individual.

D. Depression: Depression can occur in individuals with Alzheimer's disease and may present with symptoms such as sadness, hopelessness, loss of interest in activities, changes in appetite or sleep patterns, and difficulty concentrating. However, the scenario primarily describes agitation and restlessness in the evening hours, which is characteristic of sundowning rather than depression.