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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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Semiprivate room.

Explanation: Medicare can cover the cost of a semiprivate room during a qualifying hospital stay or skilled nursing facility stay.

B. Hospice care.

Explanation: Medicare provides coverage for hospice care for individuals with a terminal illness and a life expectancy of six months or less.

C. Custodial care.

Explanation: Custodial care, which involves assistance with activities of daily living (ADLs) such as bathing, dressing, and feeding, is generally not covered by Medicare. Medicare primarily covers medically necessary and skilled care, such as hospital stays, certain nursing home stays, hospice care, and some home health care services. Custodial care, which focuses on assistance with routine personal care, is considered non-medical and is typically not covered by Medicare.

D. Skilled care.

Explanation: Medicare covers skilled care, including services provided by healthcare professionals such as nurses and therapists, when deemed medically necessary. Skilled care is typically required to improve or maintain a person's condition.

A. Night lights B. Excess clutter C. Loose carpeting on the floors D. Railings on the stairway E. The use of a cane

Correct Answer is ["B","C"]

Explanation

A. Night lights

Explanation: Night lights can enhance visibility during nighttime, reducing the risk of falls. The nurse may actually recommend using night lights strategically to illuminate pathways, especially in areas like hallways and bathrooms.

B. Excess clutter

Explanation: Excess clutter on floors can increase the risk of tripping and falling. Removing or organizing clutter helps create a safer environment for the older adult.

C. Loose carpeting on the floors

Explanation: Loose or wrinkled carpeting poses a tripping hazard. The nurse may recommend securing or replacing loose carpeting to prevent falls.

D. Railings on the stairway

Explanation: Railings on stairways are important safety features that provide support and stability. The nurse would likely recommend maintaining or installing railings to enhance stair safety.

E. The use of a cane

Explanation: If prescribed by a healthcare professional, the use of a cane can improve stability and balance for an older adult. The nurse may not recommend eliminating the use of a cane but may instead ensure that the client is using it correctly and that it is in good condition.

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As a nurse caring for a cognitively impaired older adult client, you need to observe for which of the following? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A home health nurse is making a home visit to an older adult client. A nurse conducts a home safety assessment and screens the environment for potential hazards for falls. The nurse recommends that the client eliminate which of the following? (Select all that apply.)

Correct Answer is ["B","C"]

Explanation

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