A nurse is planning care for a client who has Alzheimer's disease and is in the terminal phase. Which of the following findings should the nurse expect?
Speech degrades to a few words
Needs assistance with finances
Requires cueing to eat
Unable to sit up
The Correct Answer is D
A. Speech degrading to a few words is characteristic of the middle stage of Alzheimer's disease. In the terminal phase, speech is often lost completely.
B. Needing assistance with finances typically occurs in the early stage of Alzheimer's, when complex cognitive tasks become difficult.
C. Requiring cueing to eat may be seen in the moderate stage, when the client still retains some functional ability but needs prompting.
D. Unable to sit up is a finding consistent with the terminal phase of Alzheimer’s disease. During this stage, clients lose motor functions and physical abilities, often becoming bedridden, nonverbal, and fully dependent for all activities of daily living.
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Related Questions
Correct Answer is B
Explanation
A. Although reporting abuse may be necessary, the priority action is ensuring the client’s immediate safety. Addressing safety first is fundamental before proceeding with other interventions.
B. The first priority in trauma-informed care is to ensure that the client is safe. Safety is essential to help the client begin the healing process, both physically and emotionally.
C. While encouraging the client to talk about their experience may be part of the therapeutic process, it is not the priority before ensuring safety. Forcing the client to talk too soon can increase distress.
D. Assessing social and family support is important but should be done after ensuring the client’s immediate safety.
Correct Answer is A
Explanation
A. Recent use of antibiotics is the greatest risk factor for developing C. difficile infection. Antibiotics disrupt the normal gut flora, allowing C. difficile to overgrow and produce toxins that cause severe diarrhea and colitis.
B. Prolonged rehabilitation stays can increase exposure to hospital-acquired infections but are not as strongly associated with C. difficile as antibiotic use.
C. Staying in the ICU can increase the risk for various infections, but it’s the antibiotic use commonly associated with ICU care that elevates C. difficile risk—not the ICU stay itself.
D. Recent surgery may raise infection risk in general, but it is not as specifically linked to C. difficile as antibiotic therapy is.
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