After receiving change-of-shift report for clients on the memory unit, which patient will the nurse see first?
A Patient who developed a new cough after eating breakfast
B Patient who is refusing to take the prescribed medications.
C Patient who has not had a bowel movement for 5 days.
D Patient who has a stage Il pressure ulcer on the coccyx
The Correct Answer is A
Choice A Rationale: The patient who developed a new cough after eating breakfast should be seen first. This sudden change in respiratory status during or after eating suggests a potential risk of aspiration, which requires immediate assessment and intervention to prevent respiratory distress or pneumonia.
Choice B Rationale: Medication refusal, while important, is not an immediate life threatening issue compared to a new cough with the potential for aspiration.
Choice C Rationale: Although constipation can be uncomfortable, it is not an acute priority compared to a new cough that may indicate a respiratory problem.
Choice D Rationale: A stage II pressure ulcer on the coccyx, while concerning, is not an immediate priority over a potential respiratory issue that requires urgent attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Rationale: Dementia is not characterized by a sudden onset of confusion. It is a gradual and progressive condition.
Choice B Rationale: Dementia can be triggered or worsened by factors like infections, but it is not primarily characterized by a high fever or dehydration.
Choice C Rationale: An altered level of consciousness is not typically associated with dementia but may occur in acute delirium.
Choice D Rationale: The nurse should explain to the family that dementia is a chronic condition that affects the brain and causes cognitive impairment, memory loss, andbehavioral changes. The nurse should also inform the family that dementia is not caused by a single factor, but by a combination of genetic, environmental, and lifestyle factors. The nurse should emphasize that dementia is not a normal part of aging, and that it has different stages and types.
Correct Answer is B
Explanation
Choice A Rationale: Sedatives may not be the first choice for managing behavioral issues in clients with Alzheimer's disease, as they can increase confusion and fall risk.
Choice B Rationale: Antipsychotics may be considered in cases where behavioral issues pose a safety concern. They can help manage agitation, aggression, and other challenging behaviors.
Choice C Rationale: Cholinesterase inhibitors are used to treat cognitive symptoms of Alzheimer's disease but may not directly address behavioral issues.
Choice D Rationale: Serotonin reuptake inhibitors are typically used to manage mood disorders and may not be the first-line choice for behavioral issues in Alzheimer's disease.
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