As a nurse caring for a cognitively impaired older adult client, you need to observe for which of the following? (Select all that apply.)
Pointing to a grimacing face or crying
Staring off into space
Aggression
Agitation
Increased confusion
Decreased passivity
Correct Answer : A,B,C,D,E
A. Pointing to a grimacing face or crying
Explanation: This behavior may indicate pain or discomfort, and it's important to assess and address the underlying cause.
B. Staring off into space
Explanation: Staring off into space may suggest disorientation or confusion. It's essential to evaluate whether this behavior is a manifestation of the client's cognitive impairment or if there are other contributing factors.
C. Aggression
Explanation: Aggression can be a behavioral expression of distress or frustration in cognitively impaired individuals. Identifying triggers and employing appropriate interventions is crucial for the safety of the client and others.
D. Agitation
Explanation: Agitation, restlessness, or pacing may be signs of discomfort, anxiety, or frustration in cognitively impaired individuals. Identifying the cause and implementing strategies to reduce agitation are essential aspects of care.
E. Increased confusion
Explanation: A sudden increase in confusion may indicate an underlying issue, such as an infection, medication side effect, or environmental change. Regular assessment of cognitive status helps in detecting changes and addressing them promptly.
F. Decreased passivity
Explanation: Passivity, or a lack of activity or initiative, is not necessarily a specific symptom commonly associated with cognitive impairment. Observing for changes in behavior, mood, and cognitive status is important, but the term "decreased passivity" is not a standard indicator of cognitive impairment. Instead, it's essential to assess for changes in behavior that may indicate distress or unmet needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. Use of resistance bands
Explanation: Resistance band exercises can improve strength and flexibility, but they may not specifically address balance as directly as Tai Chi or certain yoga poses.
B. Stretching
Explanation: Stretching exercises contribute to flexibility and can be part of a well-rounded exercise routine. While they can be beneficial, other exercises like Tai Chi and yoga may have a more specific focus on balance improvement.
C. Tai Chi
Explanation: Tai Chi is a low-impact exercise that emphasizes slow, controlled movements, weight shifting, and mindfulness. It has been shown to improve balance and reduce the risk of falls, making it suitable for individuals at high risk.
D. Yoga
Explanation: Yoga incorporates balance, flexibility, and strength exercises. Certain yoga poses can help improve balance and stability, making it beneficial for individuals at risk for falls.
E. Range of Motion (ROM) activities
Explanation: Range of motion activities helps maintain joint flexibility and can contribute to improved balance. Encouraging the client to perform gentle range of motion exercises can be beneficial.
Correct Answer is ["B","C","D","E"]
Explanation
A. Hearing.
While hearing impairment can affect overall awareness, it is not as directly linked to the risk of falls as vision, cognitive disorders, and blood pressure-related issues.
B. Vision.
Correct. Visual impairment can contribute to an increased risk of falls.
C. Cognitive disorders.
Correct. Cognitive impairment or disorders can impact a person's awareness and ability to navigate their environment safely.
D. Preprandial hypotension.
Correct. Low blood pressure before meals (preprandial hypotension) can contribute to dizziness and falls, especially in older adults.
E. Orthostatic hypotension.
Correct. Orthostatic hypotension, a drop in blood pressure upon standing, is a risk factor for falls.
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