A nurse is collecting data from the family members of a client who has Alzheimer's disease. Which of the following findings should the nurse identify is the priority and requires immediate intervention?
Social withdrawal
Wandering outside at night
Difficulty articulating words
Inability to remember their partner's name
The Correct Answer is B
A) Social withdrawal: While social withdrawal can be a sign of depression or a worsening cognitive decline in clients with Alzheimer's disease, it does not immediately threaten the client's safety. It is important to monitor and address, but it is not the priority concern that requires immediate intervention.
B) Wandering outside at night: This is the priority issue and requires immediate intervention. Wandering, especially at night, poses a significant safety risk to clients with Alzheimer's disease. The client may become lost, disoriented, or fall, leading to injury. Immediate steps should be taken to ensure the environment is safe, such as installing locks or alarms on doors, and potentially seeking further evaluation or care interventions to manage this behavior.
C) Difficulty articulating words: Difficulty with speech or articulation can occur as part of Alzheimer's disease, especially in the later stages. While it can be distressing for the client and family, it does not present an immediate threat to the client's safety. This issue should be addressed as part of the overall care plan, but it is not as urgent as wandering.
D) Inability to remember their partner's name: Memory loss, including difficulty remembering names, is a common symptom of Alzheimer's disease. While it can be emotionally difficult for both the client and their family, it does not pose an immediate risk to the client’s safety or well-being. This symptom should be monitored, but it is not the top priority for immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) "A child who has leukemia and an absolute neutrophil count of 200/mm³ (2,500 to 8,000/mm³)."
This child is at significant risk for infection due to a severely low neutrophil count, indicating severe neutropenia. Discharge planning for this child would be inappropriate at this time since they need intensive monitoring and care to manage their immunocompromised status and prevent infections.
B) "A child who has a new diagnosis of type 1 diabetes mellitus and is receiving IV insulin."
This child is appropriate for discharge planning. A new diagnosis of type 1 diabetes requires thorough teaching for the family and child about blood glucose monitoring, insulin administration, dietary adjustments, and emergency management. While the child is receiving IV insulin in the hospital, once stabilized, they can be discharged with proper education and support to manage their condition at home.
C) "An adolescent who has cystic fibrosis and is receiving their yearly tune-up."
A cystic fibrosis "tune-up" refers to a period of treatment, often including IV antibiotics and respiratory therapy, to help manage the chronic condition. Since this is part of ongoing care and not an acute issue, discharge planning is not immediately appropriate until the "tune-up" is complete, and the adolescent has stabilized.
D) "An infant who has respiratory syncytial virus (RSV) and a respiratory rate of 70/min."
This infant is at risk for respiratory distress and requires close monitoring. A respiratory rate of 70/min in an infant is elevated, and the child may need additional respiratory support. Discharge planning should not be initiated until the infant's condition improves and they are stable enough to handle care at home.
Correct Answer is D
Explanation
A) Nausea:
Epinephrine is not typically used to treat nausea. Nausea is usually addressed with antiemetic medications. Epinephrine, an adrenergic agonist, works by stimulating the sympathetic nervous system to alleviate symptoms related to anaphylaxis, such as difficulty breathing or hypotension, but not nausea.
B) Hyperglycemia:
While epinephrine can increase blood sugar levels by stimulating the release of glucose from the liver, it is not used to treat hyperglycemia. Hyperglycemia management typically involves insulin or other medications designed to lower blood sugar, not epinephrine. Therefore, it is not an appropriate indication for this medication.
C) Hand tremors:
Hand tremors are a possible side effect of epinephrine due to its stimulatory effects on the sympathetic nervous system. However, tremors are not an indication for administering epinephrine. The purpose of an epinephrine auto-injector is not to treat tremors but rather to manage more serious conditions, like anaphylactic reactions.
D) Shortness of breath:
Epinephrine is commonly used in emergencies, such as anaphylactic reactions, to alleviate shortness of breath, which occurs due to bronchoconstriction. Epinephrine works by stimulating alpha and beta receptors, causing bronchodilation and improving airflow. This makes it effective in treating shortness of breath caused by allergic reactions or anaphylaxis.
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