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 B
Explanation
It is important for the client to remain still during the recording of a 12-lead ECG to obtain accurate and clear readings of the heart's electrical activity.
The orthopneic position (sitting upright and leaning forward) is typically used to help relieve shortness of breath in clients with respiratory distress and is not directly related to obtaining a 12-lead ECG.
Attaching a blood pressure cuff is not necessary for obtaining a 12-lead ECG, as it measures blood pressure and not the electrical activity of the heart.
A mild stinging sensation is not expected during the test. The electrodes used to record the ECG are typically adhesive and do not cause discomfort to the client
Correct Answer is C
Explanation
Choice A Reason:
Documenting the event in the client's progress notes is not the immediate action to take. While it's important to document significant events, the priority is to stop the unauthorized disclosure of the client's information and address the privacy breach.
Choice B Reason:
Informing the client of the APs' actions is not the initial step to take. The priority is to address the issue and stop the conversation to prevent further disclosure of confidential information. However, the client may need to be informed about the breach of privacy as part of the organization's protocol.
Choice C Reason:
Telling the APs to stop the conversation is correct. Overhearing discussions about a client's personal information by unauthorized personnel is a breach of patient privacy and confidentiality, which is a serious violation of healthcare ethics and regulations. Therefore, the nurse should address the situation immediately by telling the assistive personnel (APs) to stop the conversation. Here's why each option is appropriate or not:
Choice D Reason:
Submitting an incident report to the risk manager is an appropriate step to take but should not be the first action. The immediate concern is to address the situation and stop the unauthorized discussion. After that, the incident should be documented and reported according to the facility's policies and procedures.
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