The nurse is caring for a client who is being admitted to the hospital with a neurocognitive disease due to Alzheimer's disease. Which action by the nurse is the priority?
Ensuring that the client takes care of their ADLS to prevent dependence.
Ensuring that the client environment is safe to prevent injury.
Ensuring that the client receives food they like to prevent anxiety.
Ensuring that the client meets the other patients to prevent social isolation.
The Correct Answer is B
A. Ensuring that the client takes care of their ADLS to prevent dependence: While promoting independence is important, ensuring safety is a higher priority to prevent immediate harm.
B. Ensuring that the client environment is safe to prevent injury: Safety is the top priority for clients with Alzheimer's due to their increased risk of falls, wandering, and other accidents. A safe environment helps prevent injuries.
C. Ensuring that the client receives food they like to prevent anxiety: Although providing familiar and preferred foods can reduce anxiety, it is not as critical as ensuring a safe environment.
D. Ensuring that the client meets the other patients to prevent social isolation: Social interaction is beneficial, but ensuring safety takes precedence to prevent potential harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["6"]
Explanation
Heart rate (110/min): 2 points
Respiratory effort (slow, weak cry): 1 point
Muscle tone (some flexion of extremities): 1 point
Reflex irritability (grimace): 1 point
Color (body pink, blue extremities): 1 point
APGAR-6
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"C"}}
Explanation
1st Trimester (Conception-13 weeks)
- Fetus has a heartbeat: The fetal heartbeat can typically be detected around 6 weeks gestation using ultrasound, marking the beginning of cardiac development in the first trimester.
2nd Trimester (14-26 weeks)
- Gender can be determined: Gender determination through ultrasound is generally possible around the 18-20 week mark in the second trimester when fetal genitalia are more distinguishable.
3rd Trimester (27-40 weeks)
- Surfactant production: Surfactant production by the fetal lungs begins in the third trimester, usually around 24-28 weeks, but continues to increase throughout the remainder of pregnancy.
- Sucking occurs: Fetal sucking movements start to develop around the 28th week and become more coordinated as the third trimester progresses.
- Fetal respiratory movements begin: Fetal respiratory movements, where the fetus practices breathing by moving the diaphragm, begin in the third trimester to prepare for life outside the womb.
- Increase in body fat: The fetus begins to accumulate more body fat in the third trimester, which helps with thermoregulation and provides energy reserves for birth and early postnatal life.
|
Finding |
1st Trimester Conception-13 weeks |
2nd Trimester 14-26 weeks |
3rd Trimester 27-40 weeks |
|
Gender can be determined |
☐ |
☒ |
☐ |
|
Surfactant production |
☐ |
☐ |
☒ |
|
Sucking occurs |
☐ |
☐ |
☒ |
|
Fetus has a heartbeat |
☒ |
☐ |
|
|
Fetal respiratory movements begin |
☐ |
☐ |
☒ |
|
Increase in body fat |
☐ |
☐ |
☐ |
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