A nurse is meeting with the caregivers of a client who has Alzheimer's disease who is at risk for wandering. Which of the following are manifestations that put the client at risk for wandering that the nurse should educate their caregivers about?

Confusion

Distress

Agitation

Depression

Distraction

Answer and Explanation

Correct Answer : A,C,E

A. Confusion: Individuals with Alzheimer's disease often experience confusion due to memory loss, disorientation, and difficulty processing information. Confusion can contribute to wandering behavior as the individual may become lost or disoriented in familiar surroundings, leading them to wander in search of familiar people or places.

C. Agitation: Agitation, characterized by restlessness, pacing, or irritability, is commonly observed in individuals with Alzheimer's disease. Agitation can be triggered by various factors such as environmental stimuli, changes in routine, or unmet needs. It can escalate and prompt wandering behavior as the individual seeks to alleviate discomfort or agitation.

E. Distraction: Individuals with Alzheimer's disease may easily become distracted by environmental stimuli or sensory cues, which can lead to wandering behavior. Distraction can impair the individual's ability to maintain attention to their surroundings, increasing the likelihood of wandering episodes.

The following options are not directly associated with wandering behavior in individuals with Alzheimer's disease:

B. Distress: While distress may be experienced by individuals with Alzheimer's disease due to various factors such as confusion, agitation, or environmental changes, it is not a specific manifestation that puts the client at risk for wandering. Distress may exacerbate wandering behavior in some cases but is not a primary risk factor.

D. Depression: Depression is a common comorbidity in individuals with Alzheimer's disease and can contribute to overall behavioral changes and functional decline. However, depression alone is not a direct manifestation that puts the client at risk for wandering. Wandering behavior is more closely associated with cognitive impairment, agitation, and environmental factors rather than depression.

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Correct Answer is D

Explanation

A. Massaging the legs frequently can exacerbate symptoms of peripheral venous disease by increasing venous pressure and worsening edema. It is not recommended for managing this condition.

B. Keeping the legs in a dependent position can further impair venous return and exacerbate symptoms. Elevating the legs above the level of the heart when possible is recommended to reduce venous congestion.

C. Decreasing activity can lead to deconditioning and worsen symptoms over time. Encouraging regular, moderate physical activity is important for improving venous circulation and overall vascular health.

D. Inspecting the legs daily for changes in color, size, and temperature is an essential component of managing peripheral venous disease. Changes such as skin discoloration, swelling, or increased warmth can indicate worsening venous insufficiency or the development of complications such as venous ulcers. Early detection allows for prompt intervention and prevention of complications.

A. The client develops bradycardia and bradypnea B. The client has metabolic alkalosis and warm extremities C. The client has hypertension and anuria D. The client has hypotension and is confused

Correct Answer is D

Explanation

A. The client develops bradycardia and bradypnea: Bradycardia (slow heart rate) and bradypnea (slow breathing rate) may indicate a slowing down of bodily functions but are not typical manifestations of postoperative shock. In postoperative shock, the body's compensatory mechanisms often lead to tachycardia (rapid heart rate) and tachypnea (rapid breathing rate) as the body tries to maintain perfusion.

B. The client has metabolic alkalosis and warm extremities: Metabolic alkalosis and warm extremities are not typically associated with postoperative shock. In shock, metabolic acidosis is more common due to tissue hypoperfusion, and extremities may become cool due to peripheral vasoconstriction as the body attempts to shunt blood to vital organs.

C. The client has hypertension and anuria: Hypertension (high blood pressure) and anuria (lack of urine output) are not indicative of postoperative shock. In shock, blood pressure typically decreases (hypotension), and oliguria or anuria may occur due to decreased renal perfusion.

D. The client has hypotension and is confused: This is the correct answer. Hypotension (low blood pressure) is a hallmark sign of shock, indicating inadequate tissue perfusion. Confusion may occur due to cerebral hypoperfusion and inadequate oxygen delivery to the brain. Confusion is a late sign of shock and indicates severe compromise of organ perfusion.

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A nurse is meeting with the caregivers of a client who has Alzheimer's disease who is at risk for wandering. Which of the following are manifestations that put the client at risk for wandering that the nurse should educate their caregivers about?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has peripheral venous disease about management of symptoms. Which of the following client statements indicates to the nurse an understanding of the teaching?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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