A client is admitted following a motor vehicle collision.
When assessing the client's level of consciousness, the nurse notes that the client no longer responds to commands.
The nurse initiates a painful stimulus and the client responds by pulling the arms inward with elbows and wrists flexed and extending the legs with the toes pointed downward.
Which action should the nurse implement?

Choice A rationale:

An altered level of consciousness is not a typical finding in Alzheimer's disease. This condition is characterized by cognitive decline and memory impairment, but consciousness itself is not directly affected.

Choice B rationale:

Rapid mood swings can occur in individuals with Alzheimer's disease due to the changes in brain structure and function. These mood swings are a common behavioral symptom. However, the more distinctive hallmark of Alzheimer's disease is the cognitive decline rather than mood swings.

Choice C rationale:

Excessive motor activity is not a prominent feature of Alzheimer's disease. Instead, individuals with Alzheimer's disease often experience a decline in motor skills and coordination as the disease progresses.

Choice D rationale:

Failure to recognize familiar objects is a common symptom of Alzheimer's disease. This is referred to as agnosia, where individuals may struggle to recognize familiar people, objects, or places. It results from the progressive damage to brain regions responsible for memory and sensory processing.

Choice A rationale:

Instill 3 mL of normal saline before suctioning. This choice is not appropriate for suctioning excessive drooling in a client with ALS. Instilling normal saline would introduce additional fluid into the oral cavity, potentially worsening the problem by increasing the amount of secretions. The goal of suctioning is to remove excess saliva and maintain a clear airway.

Choice B rationale:

Instruct the client to cough as the suction tip is removed. Instructing the client to cough during suctioning is not a recommended practice. It may cause discomfort and can lead to an increased risk of aspiration as the client might inhale while coughing during the procedure.

Choice C rationale:

Apply a water-soluble lubricant to the catheter. Applying a water-soluble lubricant to the suction catheter is a common practice to facilitate the passage of the catheter and minimize irritation to the client's oral tissues. While it is a helpful step, it is not the primary action that should be taken to ensure the safety of the procedure.

Choice D rationale:

Wear protective goggles while performing the procedure. This is the correct choice. When suctioning a client's oral cavity, especially when dealing with excessive drooling or secretions, it is essential for the nurse to wear protective goggles. These goggles protect the nurse's eyes from potential exposure to the client's bodily fluids, reducing the risk of infection transmission.