A nurse is planning care for a client who has dementia and lives at home. Which of the following physiological changes should the nurse educate the client and family to monitor?

Weight loss

Decreased mobility

Increased physical activity

Unkempt appearance

Constipation

Answer and Explanation

Correct Answer : A,B,C,D,E

A. Weight loss:

Weight loss can occur in individuals with dementia due to various factors, including decreased appetite, difficulty eating or swallowing, and increased energy expenditure.

Monitoring weight regularly can help detect changes in nutritional status and identify potential health concerns, such as malnutrition or dehydration.

B. Decreased mobility:

Individuals with dementia may experience a decline in mobility and functional abilities as the disease progresses.

Monitoring changes in mobility, such as difficulty walking, transferring, or performing activities of daily living, is important for assessing functional decline and implementing appropriate interventions to maintain mobility and prevent complications such as falls.

C. Increased physical activity:

While dementia can lead to decreased physical activity in some individuals, others may exhibit increased restlessness or wandering behaviors.

Monitoring changes in physical activity levels can help identify agitation, restlessness, or wandering behaviors that may require intervention to ensure the safety and well-being of the individual with dementia.

D. Unkempt appearance:

Individuals with dementia may neglect personal hygiene and grooming tasks, leading to an unkempt appearance.

Monitoring changes in appearance, such as poor personal hygiene, disheveled clothing, or neglect of grooming habits, can indicate difficulties with self-care and may necessitate assistance or supervision to maintain hygiene and appearance.

E. Constipation:

Constipation is a common gastrointestinal symptom in individuals with dementia, often due to factors such as reduced fluid intake, decreased physical activity, and side effects of medications.

Monitoring bowel habits and addressing constipation promptly can help prevent discomfort, complications such as fecal impaction, and maintain overall gastrointestinal health in individuals with dementia.

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Correct Answer is D

Explanation

A. Completing hourly endotracheal suctioning: Hourly endotracheal suctioning is not typically indicated for a client with increased intracranial pressure (ICP). Frequent suctioning can lead to increased intrathoracic pressure and potentially compromise venous return, which may further elevate ICP. Suctioning should be performed as needed to maintain airway patency while minimizing the risk of increasing ICP.

B. Ensuring proper ventriculostomy transducer levels: Ensuring proper ventriculostomy transducer levels is important for accurate measurement of intracranial pressure (ICP) but may not directly alleviate elevated ICP. Monitoring ICP through ventriculostomy allows for timely detection of changes in ICP, which can guide interventions to manage elevated pressure levels. However, it is not a direct intervention to reduce ICP.

C. Monitoring volume status: Monitoring volume status is important in managing a client with increased intracranial pressure (ICP) as both hypovolemia and hypervolemia can impact ICP. However, monitoring volume status alone does not directly address elevated ICP. Interventions to optimize volume status, such as fluid administration or diuresis, may be implemented based on assessment findings, but they should be done cautiously to avoid exacerbating cerebral edema or altering cerebral perfusion.

D. Elevating the head of the bed 15°: Elevating the head of the bed 15° (or higher) is a crucial intervention for managing a client with increased intracranial pressure (ICP). This position helps promote venous drainage from the brain, reducing venous congestion and intracranial pressure. Elevating the head of the bed also helps prevent cerebrospinal fluid (CSF) from pooling in the brain, which can further increase ICP. Placing the client in a semi-upright position is a standard practice in managing ICP and is recommended in various clinical guidelines.

A. "Endolymph fluid provides protection to the structures of the inner ear." B. "Aqueous humor provides protection to the structures of the inner ear." C. "Vitreous humor provides protection to the structures of the inner ear." D. "Sanguineous fluid provides protection to the structures of the inner ear."

Correct Answer is A

Explanation

A. "Endolymph fluid provides protection to the structures of the inner ear": Endolymph is a fluid found within the membranous labyrinth of the inner ear. It plays a crucial role in maintaining the balance of ions necessary for proper sensory function of the auditory and vestibular systems. Endolymph helps protect the delicate sensory structures of the inner ear, including the hair cells responsible for hearing and balance.

B. "Aqueous humor provides protection to the structures of the inner ear": Aqueous humor is a clear fluid that fills the anterior chamber of the eye, maintaining intraocular pressure and nourishing the cornea and lens. It is not involved in protecting the structures of the inner ear.

C. "Vitreous humor provides protection to the structures of the inner ear": Vitreous humor is a gel-like substance that fills the posterior chamber of the eye, providing structural support to the eyeball and maintaining its shape. It is not associated with protecting the structures of the inner ear.

D. "Sanguineous fluid provides protection to the structures of the inner ear": Sanguineous fluid refers to blood or a blood-like fluid, which does not directly provide protection to the structures of the inner ear. While the circulatory system supplies oxygen and nutrients to the inner ear structures, blood itself does not serve as a protective fluid within the inner ear.

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A nurse is planning care for a client who has dementia and lives at home. Which of the following physiological changes should the nurse educate the client and family to monitor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse plan to include in the plan of care?

Correct Answer is D

Explanation

A nurse is teaching a group of clients about the specific types of fluids that protect the structures of the inner ear. Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

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