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","E","F"]
Explanation
A. Functional status
Explanation: Assessing the functional status helps determine the individual's ability to perform daily activities independently. Identifying any decline in function can guide interventions to prevent future falls.
B. Medical history
Explanation: A comprehensive medical history review can reveal any pre-existing conditions, medications, or health issues that may contribute to falls. Understanding the individual's medical background is crucial for effective fall prevention strategies.
C. Financial status
Explanation: Financial status is generally not directly relevant to post-fall prevention assessments. While financial difficulties may have an impact on an individual's ability to access certain resources, it is not a primary consideration in fall prevention assessments.
D. Occupational history
Explanation: Occupational history is not a standard component of a post-fall prevention assessment. The focus should be on functional status and physical abilities rather than specific details of the individual's occupational history.
E. Physical status
Explanation: Evaluating the physical status includes assessing balance, strength, gait, and mobility. Identifying physical impairments can guide targeted interventions to address specific risk factors for falls.
F. Environment
Explanation: Assessing the environment involves identifying potential hazards in the home or care setting that could contribute to falls. Modifying the environment to enhance safety is an important aspect of fall prevention.
Correct Answer is C
Explanation
A. Driving in heavy traffic is fine as long as it is not raining.
Explanation: Driving in heavy traffic can pose challenges for individuals, especially those who may experience age-related changes in vision, reaction time, and cognitive function. The recommendation is to avoid heavy traffic, especially if it might increase stress and the likelihood of accidents.
B. If you have a passenger, you may drive at any time of the day.
Explanation: The presence of a passenger does not necessarily eliminate the potential challenges associated with age-related changes in driving abilities. It is important for older individuals to consider factors such as time of day, visibility, and overall driving conditions.
C. Limit driving to familiar places close to home.
Explanation: Limiting driving to familiar places close to home is a safer practice for older individuals who may face challenges with vision, reaction time, and other factors that can impact driving. Familiar routes are more likely to be navigated confidently, reducing the risk of getting lost or encountering unexpected challenges.
D. Playing music will help keep you alert.
Explanation: While playing music can be enjoyable, it may not be an effective strategy for maintaining alertness, especially during challenging driving conditions. The focus should be on adopting safe driving habits and minimizing distractions to ensure overall safety on the road.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.