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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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Defecation less than once each day is not necessarily constipation.

Explanation: The frequency of bowel movements varies among individuals, and defecating less than once each day does not necessarily indicate constipation. Normal bowel habits can differ, and what is considered regular for one person may not be the same for another. Constipation is better assessed by considering other factors such as stool consistency, straining during bowel movements, and feelings of incomplete evacuation.

B. Leaking liquid feces should be treated as diarrhea.

Explanation: Leaking liquid feces may be indicative of diarrhea, but it is not the only factor to consider. The cause of diarrhea should be investigated, and treatment will depend on the underlying reason, which may include infections, medications, or other medical conditions.

C. Mineral oil is recommended as a laxative for the older adult.

Explanation: Mineral oil is generally not recommended as a laxative for older adults. It can interfere with the absorption of fat-soluble vitamins and may have adverse effects. There are other safer and more effective laxative options that healthcare providers may recommend.

D. Excessive sleep can be a symptom of constipation.

Explanation: Excessive sleep is not typically considered a symptom of constipation. Constipation is more commonly associated with symptoms such as infrequent bowel movements, difficulty passing stool, and abdominal discomfort. Sleep disturbances may have various causes, but they are not a direct symptom of constipation.

A. Constipation B. Poor solid food intake C. Poor liquid intake D. Diarrhea

Correct Answer is A

Explanation

A. Constipation is a common side effect of opioid medications like morphine. It is a priority to address because constipation can lead to discomfort, increased pain, and other complications. Preventive measures such as increased fiber intake, adequate hydration, and bowel regimen may be necessary.

B. Poor solid food intake and C. poor liquid intake are concerns, but they are secondary to the immediate issue of constipation. Adequate nutrition and hydration are important for overall recovery, but constipation can have more immediate and uncomfortable consequences.

D. Diarrhea is not a common side effect of morphine. In fact, constipation is a more common gastrointestinal side effect. If the patient were to experience diarrhea, it could be indicative of another issue or complication that needs to be addressed, but it is not the primary preventive care concern associated with morphine use.

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As a nurse caring for a cognitively impaired older adult client, you need to observe for which of the following? (Select all that apply.)

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