A nurse is assessing a client who recently experienced the loss of their partner.
Which of the following questions is the priority for the nurse to ask during this situational crisis?

Choice B rationale:

Offering the client food and fluids every 2 hours is not the most appropriate action in this situation. When a client has been placed in seclusion due to physical aggression, their safety and the safety of the staff must be the top priority. It is essential to monitor the client's behavior and document it regularly to ensure they do not pose a threat to themselves or others.

Choice C rationale:

Monitoring the client's vital signs every 4 hours is not the highest priority when a client has become physically aggressive and is placed in seclusion. Vital sign monitoring is important for the overall assessment of a client's health, but it may not address the immediate safety concerns associated with aggressive behavior. Regular observation and documentation of the client's behavior are more critical in this situation.

Choice D rationale:

Obtaining the provider's prescription within 60 minutes is an important step, but it is not the most immediate priority. While it is essential to have a healthcare provider's order for seclusion, the safety of the client and staff takes precedence. Documenting the client's behavior every 15 minutes allows for ongoing assessment of their condition and ensures their well-being during the time leading up to obtaining the provider's order.

A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect? The correct answer is choice B: Failure to recognize familiar objects.

Choice A rationale:

Excessive motor activity Individuals with Alzheimer's disease typically exhibit a decline in motor activity rather than excessive motor activity. As the disease progresses, they may become less mobile and experience difficulties with movement due to cognitive and physical impairments.

Choice C rationale:

Altered level of consciousness While individuals with Alzheimer's disease may experience changes in cognitive function, including memory loss and confusion, they do not typically have altered levels of consciousness. They remain conscious and aware of their surroundings, but they struggle with recognizing familiar objects and people.

Choice D rationale:

Rapid mood swings Rapid mood swings are not a prominent feature of Alzheimer's disease. Mood changes are more commonly associated with other psychiatric conditions. In Alzheimer's disease, individuals tend to exhibit personality changes, such as becoming more withdrawn or agitated, but these changes are not rapid mood swings.