A nurse is caring for a client who has dementia.
Which of the following findings should the nurse expect?
Memory loss that disrupts ADLs
Catatonia
Illusions
Pressured speech
The Correct Answer is A
a. Memory loss that disrupts ADLs
Explanation: Dementia is a condition characterized by a decline in cognitive function that affects a person's ability to perform activities of daily living (ADLs). Memory loss is a common symptom of dementia, particularly in the early stages. The memory loss can disrupt a person's ability to carry out tasks they were previously able to do independently, such as dressing, bathing, and eating. Therefore, option a is the correct answer.
Option b, catatonia, is a condition characterized by a lack of movement or activity, which is not typically associated with dementia.
Option c, illusions, involve a misinterpretation of sensory information and may occur in some forms of dementia but are not a defining feature.
Option d, pressured speech, is a symptom commonly associated with mania or bipolar disorder, but is not typically seen in dementia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Raises all four side-rails on the client's bed .The nurse should intervene when the assistive personnel (AP) raises all four side-rails on the client's bed. Using all four side-rails on the bed is considered a restraint, and its use should be avoided unless there is a specific clinical indication and an order from the healthcare provider. Restraints should only be used when less restrictive alternatives have been attempted and are not successful in preventing the client from falling.
Choice B Reason:
Assisting the client to the bathroom every 2 hours is a proactive measure to help the client maintain their continence and reduce the risk of falls associated with trying to get to the bathroom independently.
Choice C Reason:
Clearing furniture from the path leading to the bathroom helps create a safe and unobstructed environment for the client to navigate.
Choice D Reason:
Locking the wheels on the client's bed is an appropriate safety measure to prevent the bed from moving while the client is getting in or out.
Correct Answer is D
Explanation
Choice A Reason:
Attaching a pacifier to the newborn's clothing with a string can be dangerous, as it poses a risk of strangulation. Pacifiers should be used, but they should be the type with a handle designed for infant use.
Choice B Reason:
Placing the newborn face up on a pillow when sleeping is not recommended. The baby should be placed on their back on a firm and flat sleep surface, such as a crib mattress, without pillows, blankets, or other soft bedding items. This helps reduce the risk of sudden infant death syndrome (SIDS).
Choice C Reason:
Placing the newborn's crib near a heat vent during cold weather can lead to overheating, which is a risk factor for SIDS. It's important to maintain a comfortable room temperature for the baby and use appropriate sleep clothing to keep them warm without the need for additional heating devices near the crib.
Choice D Reason:
"I will make sure that I can fit one finger between the mattress and the side of my newborn's crib." This statement indicates an understanding of safe sleep practices for newborns. Ensuring that there is a small gap (about one finger's width) between the mattress and the side of the crib helps prevent the risk of suffocation or entrapment. It allows for proper airflow and reduces the risk of the baby getting stuck between the mattress and the crib.
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