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","D","E","F"]
Explanation
To decrease the risks of a urinary tract infection for this client, the nurse should take several actions. The nurse should encourage the client to drink 3,000 mL of fluid daily to help flush bacteria out of the urinary tract¹. The nurse should also empty the drainage bag when it is half-full to prevent bacterial growth¹.
Additionally, the nurse should review the need for the indwelling urinary catheter daily and use soap and water to provide perineal care¹.
Correct Answer is ["C","D","E","F"]
Explanation
A. Inform the client that an advance directive discontinues further care.This statement is incorrect. An advance directive does not discontinue further care but outlines the client's preferences for medical treatment if they become unable to communicate their wishes.
B. Initiate a power of attorney for health care documents.This is not the nurse's responsibility. Initiating a power of attorney for health care documents typically involves legal consultation, and the client should be referred to appropriate resources.
C. Document that the provider discussed do-not-resuscitate status with the client.This is correct. The nurse should document that the provider has discussed DNR (Do Not Resuscitate) status with the client, ensuring that the discussion and decision are clearly recorded in the medical record.
D. Provide the client with written information about advance directives.This is correct. The nurse is responsible for providing the client with written information about advance directives, ensuring the client understands their rights and options.
E. Communicate advance directives status via the medical record and shift report.This is correct. The nurse must ensure that the client's advance directive status is clearly communicated in the medical record and during shift reports to ensure continuity of care.
F. Instruct the client that an advance directive is a legal document and must be honored by care providers.This is correct. The nurse should inform the client that an advance directive is a legal document that healthcare providers are required to honor, according to the client's wishes.
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