As a nurse caring for a cognitively impaired older adult client, you need to observe for which of the following? (Select all that apply.)
Pointing to a grimacing face or crying
Staring off into space
Aggression
Agitation
Increased confusion
Decreased passivity
Correct Answer : A,B,C,D,E
A. Pointing to a grimacing face or crying
Explanation: This behavior may indicate pain or discomfort, and it's important to assess and address the underlying cause.
B. Staring off into space
Explanation: Staring off into space may suggest disorientation or confusion. It's essential to evaluate whether this behavior is a manifestation of the client's cognitive impairment or if there are other contributing factors.
C. Aggression
Explanation: Aggression can be a behavioral expression of distress or frustration in cognitively impaired individuals. Identifying triggers and employing appropriate interventions is crucial for the safety of the client and others.
D. Agitation
Explanation: Agitation, restlessness, or pacing may be signs of discomfort, anxiety, or frustration in cognitively impaired individuals. Identifying the cause and implementing strategies to reduce agitation are essential aspects of care.
E. Increased confusion
Explanation: A sudden increase in confusion may indicate an underlying issue, such as an infection, medication side effect, or environmental change. Regular assessment of cognitive status helps in detecting changes and addressing them promptly.
F. Decreased passivity
Explanation: Passivity, or a lack of activity or initiative, is not necessarily a specific symptom commonly associated with cognitive impairment. Observing for changes in behavior, mood, and cognitive status is important, but the term "decreased passivity" is not a standard indicator of cognitive impairment. Instead, it's essential to assess for changes in behavior that may indicate distress or unmet needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. The Global Deterioration Scale
Explanation: The Global Deterioration Scale (GDS) is a tool used to assess the cognitive function and stage of cognitive decline in individuals, especially those with dementia.
B. Mini Mental State Exam (MMSE)
Explanation: The Mini Mental State Exam (MMSE) is a widely used tool to assess cognitive function and screen for cognitive impairment. It evaluates various cognitive domains, including orientation, memory, attention, and language.
C. Older American's Resources and Services (OARS)
Explanation: The Older American's Resources and Services (OARS) is not a cognitive assessment tool. It is a comprehensive assessment tool that covers various domains, including physical health, mental health, and social resources.
D. Mini-Cog
Explanation: The Mini-Cog is a brief cognitive screening tool that includes a three-item recall test for memory and a clock-drawing task. It is used to quickly assess cognitive function and detect potential cognitive impairment.
E. The Barthel Index
Explanation: The Barthel Index is not a cognitive assessment tool. It is a tool used to assess an individual's ability to perform activities of daily living (ADLs), providing information about their functional independence rather than cognitive status.
Correct Answer is C
Explanation
A. Hospice care.
Explanation: Both Medicare Part A and Part B cover hospice care, and hospice care is not a fundamental difference between the two parts.
B. Home care services.
Explanation: Both Medicare Part A and Part B cover certain home care services. While the specific services covered may vary, home care services are not a fundamental difference between the two parts.
C. Health care setting.
Explanation: Medicare Part A and Part B cover different aspects of healthcare and are designed for different health care settings.
Medicare Part A (Hospital Insurance): Primarily covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health care services. It is generally associated with institutional settings.
Medicare Part B (Medical Insurance): Covers outpatient care, preventive services, doctor visits, and some home health care services. It is more focused on services provided in non-institutional settings.
D. Invasive procedures.
Explanation: Both Medicare Part A and Part B cover various medical services, including invasive procedures. The nature of procedures covered may differ, but it is not a fundamental difference distinguishing between Part A and Part B.
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