A nurse is visiting a client who has Alzheimer's disease in their home. The client's spouse states that the client gets increasingly agitated and restless in the evening hours and can sometimes be difficult to calm down. Which of the following behaviors does the nurse recognize that the client is experiencing?
Relocation stress syndrome
Wandering
Sundowning
Depression
The Correct Answer is C
A. Relocation stress syndrome: Relocation stress syndrome refers to the physical and psychological symptoms experienced by individuals when they are moved from one environment to another, such as transitioning to a new residence or healthcare facility. While relocation stress syndrome can cause agitation and confusion in individuals with Alzheimer's disease, the scenario provided does not indicate a recent relocation.
B. Wandering: Wandering is a common behavior observed in individuals with dementia, where they aimlessly roam or wander in their environment. While wandering may be associated with agitation and restlessness, the scenario does not describe the client physically moving around or attempting to leave their home.
C. Sundowning: Sundowning refers to a phenomenon commonly observed in individuals with Alzheimer's disease or other forms of dementia, where they experience increased agitation, confusion, and restlessness in the late afternoon or early evening hours. Sundowning behaviors can include pacing, agitation, anxiety, irritability, confusion, and difficulty sleeping. The exact cause of sundowning is not fully understood but may be related to factors such as fatigue, sensory overload, hormonal imbalances, or disruptions in the sleep-wake cycle. Managing sundowning behaviors often involves creating a calming environment, maintaining a consistent daily routine, minimizing stimuli in the evening, and providing reassurance and comfort to the individual.
D. Depression: Depression can occur in individuals with Alzheimer's disease and may present with symptoms such as sadness, hopelessness, loss of interest in activities, changes in appetite or sleep patterns, and difficulty concentrating. However, the scenario primarily describes agitation and restlessness in the evening hours, which is characteristic of sundowning rather than depression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Creatine kinase (CK) test: While creatine kinase isoenzymes, including CK-MB, can be elevated following myocardial infarction (MI), they are not specific to cardiac muscle injury. CK is found in various tissues throughout the body, so elevated levels can also indicate damage to skeletal muscle or brain tissue, among other sources.
B. Creatine kinase-myocardial band (CK-MB) test: CK-MB is a cardiac-specific isoform of creatine kinase, and elevated levels can indicate myocardial injury, particularly in the context of an acute MI. However, troponin T is a more sensitive and specific marker for myocardial injury.
C. Brain natriuretic peptide (BNP) test: Brain natriuretic peptide is primarily used in the diagnosis and management of heart failure. While elevated BNP levels can indicate heart muscle strain or stress, they are not specific markers for acute myocardial infarction or early injury to the cardiac muscle.
D. Troponin T test: This is the correct answer. Troponin T is a highly specific marker for cardiac muscle injury. Elevated troponin levels can be detected within hours of myocardial infarction and persist for several days, making it an essential tool in the diagnosis of acute coronary syndromes, including myocardial infarction. Troponin T is considered one of the gold standard biomarkers for detecting early injury to the cardiac muscle.
Correct Answer is ["A","B","C","D","E"]
Explanation
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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