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 D
Explanation
A. A CT angiogram will reveal any edema within the brain tissue: CT angiography primarily focuses on visualizing blood vessels and blood flow within the brain. While it may incidentally detect areas of edema, its primary purpose is to assess vascular structures rather than brain tissue changes such as edema.
B. A CT angiogram will reveal any overproduction of cerebrospinal fluid (CSF): CT angiography does not assess cerebrospinal fluid (CSF) production. Its main function is to visualize blood vessels and blood flow within the brain, particularly to detect abnormalities such as aneurysms, arteriovenous malformations, or vasospasm.
C. A CT angiogram will reveal any fractures within the skull or spine: CT angiography primarily focuses on imaging blood vessels and is not the preferred modality for detecting fractures within the skull or spine. CT scans or plain radiography are typically used to assess bony structures for fractures.
D. A CT angiogram will reveal any decreased blood flow related to vasospasm: This statement is correct. CT angiography is a specialized imaging technique that combines computed tomography (CT) scanning with contrast dye to visualize blood vessels and blood flow within the brain. It is commonly used to detect and monitor vasospasm, a potentially serious complication of subarachnoid hemorrhage, where blood vessels in the brain constrict, leading to decreased blood flow. CT angiography allows for the visualization of these changes in blood vessel diameter and blood flow dynamics.
Correct Answer is ["B","C"]
Explanation
A. Difficulty swallowing: Difficulty swallowing is not typically associated with atrial fibrillation. It may be a symptom of various other conditions such as dysphagia, esophageal disorders, or neurological disorders, but it is not a common manifestation of atrial fibrillation.
B. Shortness of breath: This is the correct answer. Shortness of breath, or dyspnea, is a common symptom of atrial fibrillation. Atrial fibrillation can lead to ineffective atrial contraction, resulting in decreased cardiac output and potential fluid accumulation in the lungs, leading to dyspnea.
C. Exertional fatigue: This is the correct answer. Exertional fatigue, or feeling excessively tired or weak with physical activity, is a common manifestation of atrial fibrillation. Reduced cardiac output and inefficient heart function due to irregular heart rhythms can lead to fatigue, especially during exertion.
D. Weight gain: Weight gain is not typically associated with atrial fibrillation. While some individuals with heart conditions may experience fluid retention and subsequent weight gain, it is not a specific manifestation of atrial fibrillation itself.
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