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 ["C","D","E","F"]
Explanation
A. Stroke under the chin in a downward motion.
Explanation: Stroking under the chin in a downward motion is not considered a standard technique for managing dysphagia. It's important to focus on strategies that promote safe swallowing and prevent aspiration.
B. Keep pulse oximeter ready at all times.
Explanation: While monitoring oxygen saturation is important in certain situations, having a pulse oximeter ready at all times may not be a routine instruction for feeding a client with dysphagia. Monitoring for signs of distress and ensuring a safe feeding environment are key aspects of care.
C. Avoid rushing the client or force feeding her.
Explanation: Rushing or force-feeding a client with dysphagia can increase the risk of aspiration. It's important to allow the client to eat at their own pace and take adequate time to chew and swallow safely.
D. If facial weakness is present, place food on the impaired side of the mouth.
Explanation: Placing food on the impaired side of the mouth can help compensate for facial weakness and promote more effective chewing and swallowing.
E. Alternate solid and liquid boluses.
Explanation: Alternating solid and liquid boluses can help with the overall coordination of the swallowing process. It can also facilitate the movement of food and liquids through the digestive tract.
F. Have the client sit at 90 degrees during all of oral intake.
Explanation: Ensuring that the client sits at a 90-degree angle during oral intake helps promote an upright position that aids in swallowing and reduces the risk of aspiration.
Correct Answer is ["A","D","E"]
Explanation
A. Facilitates remote physical assessment and monitoring of chronic conditions
Explanation: Telehealth technology allows healthcare providers to remotely assess and monitor chronic conditions, enabling timely interventions and personalized care plans.
D. Promotes self-management of illness in rural and underserved areas
Explanation: Telehealth technology can help individuals in rural and underserved areas access healthcare services and information, promoting self-management of illnesses and improving overall health outcomes.
E. Decreases costs by reducing hospital readmissions
Explanation: Telehealth technology can contribute to reducing hospital readmissions by enabling remote monitoring, early detection of issues, and timely interventions, ultimately lowering healthcare costs associated with avoidable hospitalizations.
The following options are not accurate in relation to the benefits of telehealth technology:
B. Decreases costs by replacing the role of the nurse with technology
Explanation: Telehealth technology is not meant to replace the role of healthcare professionals, including nurses. Instead, it enhances their ability to provide care by extending access to patients, facilitating communication, and improving monitoring. The goal is to complement healthcare services rather than replace them.
C. Reimbursed by all health care insurances
Explanation: While reimbursement for telehealth services has expanded, it is not universally covered by all healthcare insurances. Coverage varies depending on the payer, state regulations, and the type of telehealth service provided. Reimbursement policies continue to evolve, and not all services may be covered by every insurance plan.
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