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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
A. Intermittent pneumatic compression pumps: Intermittent pneumatic compression pumps can help improve circulation in the lower extremities by assisting with venous return. These devices inflate and deflate sequentially, promoting venous blood flow and reducing edema in clients with peripheral venous disease.
B. Ankle-brachial index test: The ankle-brachial index (ABI) test is a non-invasive vascular study used to assess peripheral arterial disease (PAD). It compares the blood pressure in the ankle with the blood pressure in the arm to evaluate arterial circulation.
C. Layered wraps: Layered wraps, such as compression bandages or stockings, are typically used in the management of venous insufficiency and venous ulcers. They are not as commonly utilized in peripheral venous disease, however, they may be beneficial for some clients with PVD.
D. Elevation of legs: Elevating the legs above the level of the heart can help reduce edema and improve venous return in clients with peripheral venous disease. Gravity assists in draining blood from the lower extremities back toward the heart, thereby reducing swelling and discomfort.
E. Exercise: Regular physical activity, particularly lower extremity exercises such as walking, can promote venous return and improve circulation in clients with peripheral venous disease. Exercise helps to pump blood back to the heart, reducing venous stasis and the risk of complications such as venous thrombosis.
Correct Answer is D
Explanation
A. A client who has coronary artery disease (CAD) and Bell's palsy: Bell's palsy, a condition characterized by sudden, temporary weakness or paralysis of the facial muscles, does not directly increase the risk of complications following CABG surgery. While Bell's palsy may affect facial muscle function, it typically does not impact respiratory function or cardiovascular stability during surgery.
B. A client who has coronary artery disease (CAD) and chronic diverticulitis: Chronic diverticulitis, inflammation or infection of the diverticula in the colon, is not directly related to increased risk for complications following CABG surgery. While diverticulitis may require medical management and dietary modifications, it does not typically affect cardiovascular or respiratory function during surgery.
C. A client who has coronary artery disease (CAD) and chronic allergies: Chronic allergies, while they may cause respiratory symptoms such as nasal congestion or rhinitis, are not typically associated with increased risk for complications following CABG surgery. Allergies alone are unlikely to significantly impact cardiovascular stability or respiratory function during surgery compared to conditions such as COPD.
D. A client who has coronary artery disease (CAD) and chronic obstructive pulmonary disease (COPD): A client with CAD and COPD is at the highest risk for complications following coronary artery bypass graft (CABG) surgery. COPD is a chronic respiratory condition characterized by airflow limitation and increased airway resistance, often accompanied by emphysema and chronic bronchitis. These respiratory impairments can significantly impact the client's ability to tolerate anesthesia, mechanical ventilation, and postoperative respiratory function. COPD increases the risk of complications such as atelectasis, pneumonia, exacerbation of COPD, and respiratory failure following CABG surgery.
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