An older adult in the middles and late stages of Alzheimer's forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the client's family?

Label the bathroom door.

Take the older adult to the bathroom hourly

Place the older adult in disposable adult briefs.

Limit the intake of oral fluids to 1000 mL/day

Answer and Explanation

The Correct Answer is C

A. Label the bathroom door: While labeling the bathroom door might be helpful in some cases, it may not be effective for a person with middle to late stages of Alzheimer's disease. They may have difficulty recognizing or interpreting written signs, and their memory and cognitive abilities may be severely impaired.
B. Take the older adult to the bathroom hourly: Taking the older adult to the bathroom hourly is a good practice to promote regular toileting. However, in the middle to late stages of Alzheimer's, the person may have significant cognitive impairment and may not always signal the need to use the bathroom. Additionally, it may not always be feasible to have someone available to assist hourly, and it may lead to caregiver burnout.
C. Place the older adult in disposable adult briefs: This is the most appropriate intervention in this situation. In the middle to late stages of Alzheimer's, individuals may have difficulty recognizing the need to use the toilet, and episodes of incontinence are common. Using disposable adult briefs helps maintain the person's dignity, prevents discomfort, and minimizes the risk of skin breakdown or infections due to incontinence.
D. Limit the intake of oral fluids to 1000 mL/day: Restricting fluid intake to such a low level is not recommended. Dehydration can have serious health consequences, and older adults, especially those with Alzheimer's, need to stay well-hydrated. Reducing fluid intake to this extent can lead to health complications and is not a suitable solution for addressing incontinence issues.

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Correct Answer is C

Explanation

A. "Attempts to communicate by using rhyming words" describes a communication pattern but does not address confabulation.
B. "Nonverbals indicate communication with unseen others" suggests a form of nonverbal communication or possibly hallucinations, but it does not directly relate to confabulation.
C. "Verbalizes happiness about trip to park which was not based in fact."
Confabulation is a symptom often observed in individuals with cognitive disorders such as dementia or delirium. It involves the creation of false or fabricated memories or information that is not based in reality. In option C, the client verbalizing happiness about a trip to the park, which did not actually occur, accurately describes confabulation. This entry indicates that the client is providing information that is not based on actual events or facts, which is a characteristic of confabulation.
D. "Rambles about early childhood experiences jumping from topic to topic" describes a form of disorganized or tangential speech but does not explicitly mention the creation of false memories or information, which is a key feature of confabulation.

A. Thiamine deficiency B. Hypothalamic and mammillary body lesions C. Inability to learn new skills and short-term memory loss D. Double vision and rapid eye movement

Correct Answer is A

Explanation

A. Wernicke encephalopathy is a neurological disorder caused by a severe deficiency of thiamine (vitamin B1), a nutrient essential for brain function. This deficiency can occur in individuals with chronic alcoholism due to poor nutrition and malabsorption.

B.Wernicke encephalopathy results from severe thiamine (vitamin B1) deficiency, and it is characterized by damage to the brain, including the hypothalamic and mammillary body lesions.

C.This describes Korsakoff syndrome, which often follows Wernicke encephalopathy and is characterized by severe memory problems, particularly anterograde amnesia (inability to form new memories).

D.These symptoms are not specific to Wernicke encephalopathy and can be caused by other neurological conditions.

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An older adult in the middles and late stages of Alzheimer's forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the client's family?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing documentation entry accurately describes a client's use of confabulation?

Correct Answer is C

Explanation

A client with chronic alcoholism has been found to have Wemicke encephalopathy. What is this irreversible complication characterized by?

Correct Answer is A

Explanation

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