A nurse is assessing a client who has Alzheimer's disease. Which of the following findings should the nurse identity as the priority?

A. Fatigue: Fatigue is a common symptom of cocaine withdrawal, as the body adjusts to the absence of the stimulant. Clients often feel extremely tired or lethargic during this phase. Depressive symptoms that accompany withdrawal can also contribute to feelings of exhaustion.

B. Hand tremors: Hand tremors are more often seen with alcohol withdrawal or neurological disorders. While tremors can occur in some cases, they are not a typical manifestation of cocaine withdrawal. The focus is more on mood and energy changes.

C. Rapid speech: Rapid speech is a sign of cocaine intoxication, not withdrawal. During withdrawal, clients tend to experience slowed speech and cognitive dulling, not the heightened energy associated with the drug.

D. Seizures: Seizures are more related to cocaine overdose or intoxication, not withdrawal. Withdrawal typically involves mood changes and fatigue rather than physical manifestations like seizures.

Rationale for correct choices:

• Ask the client if they have been hit, slapped, or kicked within the past year: This question is specific and nonjudgmental, helping the client disclose abusive behaviors without feeling pressured. It's important for identifying signs of abuse that may not be immediately obvious.
• Ask the client to clarify the circumstances of their injuries: Clarifying the circumstances of the injuries helps the nurse assess the situation and detect any discrepancies in the explanation that may suggest abuse. It can also guide the next steps in care and safety planning.
• Discuss with the client the factors that precipitate violence: Identifying triggers and patterns of violence empowers the client to recognize and avoid dangerous situations, and to plan for their safety moving forward.

Rationale for incorrect choices:

• Interview the client with another nurse present: The primary goal during is to establish a private and trusting environment where the client feels safe to disclose. The presence of another person can make a client feel less comfortable and less likely to speak openly about sensitive issues like intimate partner violence.
• Ask questions in different ways until the client provides an answer: Repeating or rephrasing questions multiple times could make the client feel pressured or coerced, which may hinder trust and open communication. It’s important to respect their pace and comfort level.
• Refrain from asking the client if they are afraid of their partner: Fear of the partner is a crucial indicator of abuse, and not asking about it may prevent the client from disclosing important information. Acknowledging fear helps assess the level of risk and urgency.
• Assure the client that their medical team feels sympathy for their injuries and disapproval for the person responsible for inflicting them: While empathy is important, making value judgments about the abuser can undermine the client's trust, making them feel judged or unsupported in their decisions.
• Inform the client that they should have fought back: Telling the client what they "should have done" may inadvertently place blame on them and discourage further disclosures. It’s vital to maintain a supportive, nonjudgmental stance to ensure the client feels safe.