A nurse is teaching the caregiver of a client who has dementia. Which of the following behaviors should the nurse identify as increasing with the progression of the disorder? (Select All that Apply.)
Hallucinations
Paranoia
Lethargy
Impulsivity
Disregard for caregiver's feelings
Correct Answer : A,B,D,E
A. Hallucinations: As dementia progresses, especially in conditions like Alzheimer's disease, sensory perceptions can become distorted, leading to hallucinations, where the person perceives things that are not present.
B. Paranoia: Paranoia, or irrational suspicions and mistrust, often increases as dementia progresses. The person may become increasingly fearful or suspicious of others, even caregivers or family members.
C. Lethargy: While lethargy can be a symptom of dementia, it is more commonly associated with the earlier stages of the disorder when the person may experience apathy, lack of interest, and reduced energy levels. As the disease progresses, other behavioral changes like agitation or restlessness may become more prominent.
D. Impulsivity: Impulsivity, or acting without forethought or consideration of consequences, can increase as dementia progresses, particularly in certain types of dementia like frontotemporal dementia. This can manifest as impulsive behaviors such as excessive spending, inappropriate social behavior, or risky actions.
E. Disregard for caregiver's feelings: As dementia advances, the person's ability to empathize or recognize the feelings and needs of others may decline. They may become increasingly self-focused or unaware of the impact of their actions on caregivers, leading to behaviors that disregard or overlook the caregiver's feelings and well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Dopamine: Dopamine is a catecholamine often used to increase blood pressure and cardiac output in hypotensive states. It does not directly reduce intracranial pressure (ICP).
B. Mannitol: Mannitol is an osmotic diuretic commonly used to reduce intracranial pressure in clients with conditions such as subarachnoid hemorrhage, traumatic brain injury, or cerebral edema. It works by drawing fluid from brain tissue into the bloodstream, thereby reducing cerebral edema and ICP.
C. Nicardipine: Nicardipine is a calcium channel blocker used primarily to lower blood pressure in hypertensive emergencies. While it can indirectly impact intracranial pressure by reducing cerebral perfusion pressure, its primary mechanism of action is not targeted at reducing ICP.
D. Phenytoin: Phenytoin is an antiepileptic medication used to prevent and control seizures. While it may be indicated in clients who have experienced a subarachnoid hemorrhage to prevent seizures, it does not directly reduce intracranial pressure.
Correct Answer is D
Explanation
A. Apply soft restraints to wrists and chest: Using restraints should only be considered as a last resort and should not be the first intervention for managing delirium. Restraints can exacerbate agitation and increase the risk of complications such as skin breakdown, musculoskeletal injury, and psychological distress. Therefore, applying restraints should not be the first action taken by the nurse.
B. Administer antipsychotic medications as prescribed: While antipsychotic medications may be used to manage symptoms of delirium in some cases, they should not be the first intervention for preventing client injury. Additionally, the use of antipsychotics in the ICU requires careful consideration due to potential adverse effects, such as sedation, hypotension, and prolongation of the QT interval. The decision to administer antipsychotic medications should be based on a comprehensive assessment and in consultation with the healthcare team.
C. Administer sedative medications as prescribed: Administering sedative medications may help calm an agitated client with delirium, but it should not be the first intervention for preventing client injury. Sedatives can further impair cognition and increase the risk of falls or other complications. Like antipsychotic medications, the use of sedatives should be based on a thorough assessment and in collaboration with the healthcare team, rather than being the initial action taken by the nurse.
D. Arrange for one-on-one observation for the client: Delirium in the intensive care unit (ICU) is a serious condition that can lead to confusion, disorientation, and an increased risk of injury to the client. The priority intervention for preventing client injury in this situation is to ensure constant monitoring and supervision. By arranging for one-on-one observation, the nurse can provide continuous monitoring of the client's behavior, assess for changes or signs of agitation, and intervene promptly to prevent falls or other injuries.
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