Mrs. Johnson, who has a diagnosis of dementia, has been admitted for acute confusion and agitation. What is the nurse's priority assessment?
Evaluate the patient's sleep patterns
Monitor the patient's blood pressure
Assess the patient's nutritional status
Assess for signs of infection
The Correct Answer is D
Choice A reason: Sleep patterns impact dementia but aren’t the priority for acute confusion. Disrupted sleep may exacerbate agitation via circadian rhythm disturbances, increasing cortisol. Scientifically, while sleep affects cognitive function, infection is a more urgent cause of acute changes, as it directly triggers neuroinflammatory responses, worsening confusion.
Choice B reason: Monitoring blood pressure is relevant for dementia patients with cardiovascular risks but not the priority for acute confusion. Hypertension may contribute to cognitive decline long-term. Scientifically, acute changes are more likely driven by infection or metabolic issues, which directly cause neuroinflammation or delirium, requiring immediate assessment.
Choice C reason: Nutritional status affects dementia progression but isn’t the primary cause of acute confusion. Malnutrition may exacerbate cognitive decline via metabolic deficiencies. Scientifically, acute agitation is more likely triggered by infection or medication, causing rapid neuroinflammatory changes, making nutritional assessment secondary to urgent causes like infection.
Choice D reason: Assessing for infection is critical, as it’s a common cause of acute confusion in dementia. Infections like UTIs trigger neuroinflammation, increasing cytokines and altering brain function. Scientifically, this causes delirium, worsening agitation and confusion, requiring immediate identification to treat the underlying cause and stabilize cognitive function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A daily routine and relaxation techniques stabilize post-disaster symptoms like nightmares or hyperarousal. Scientifically, routines reduce cortisol, while relaxation calms amygdala activity, promoting emotional regulation. This mitigates trauma’s neurobiological impact, supporting recovery from acute stress or PTSD by fostering predictability and calm.
Choice B reason: Immediate psychiatric referral for medication is premature without assessment. Symptoms like nightmares stem from trauma-induced neural changes. Scientifically, unguided medication risks inappropriate treatment, potentially disrupting neurotransmitter balance and delaying psychological stabilization, as specific trauma needs must be evaluated first for effective care.
Choice C reason: Avoiding trauma discussion may suppress processing, worsening symptoms. Scientifically, unaddressed trauma increases amygdala-driven hyperarousal and cortisol, risking chronic PTSD. Encouraging avoidance delays recovery by preventing engagement with therapeutic interventions needed to reframe trauma’s psychological and neurobiological impact effectively.
Choice D reason: Isolation exacerbates symptoms by limiting support. Post-disaster stress involves heightened amygdala activity, and isolation increases cortisol, worsening anxiety. Scientifically, social withdrawal delays trauma processing, risking chronic mental health issues, as engagement with support systems is critical for stabilizing neurobiological responses and recovery.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason: Monitoring vital signs tracks withdrawal complications, like tachycardia, in alcohol use disorder. Scientifically, withdrawal causes autonomic arousal and glutamate hyperactivity, risking seizures. Regular monitoring ensures early detection of neurobiological instability, guiding interventions to stabilize physiological responses and ensure patient safety during detoxification.
Choice B reason: Fall precautions prevent injuries during withdrawal, as confusion increases risk. Scientifically, alcohol withdrawal disrupts GABA and glutamate balance, causing disorientation. Implementing precautions addresses motor and cognitive impairments, ensuring safety by mitigating neurobiological instability’s impact on physical coordination during acute detoxification phases.
Choice C reason: Hydration and electrolyte support correct imbalances from alcohol withdrawal. Dehydration and hypokalemia risk seizures due to glutamate hyperactivity. Scientifically, restoring electrolytes stabilizes neural function, preventing complications like delirium tremens, supporting physiological recovery and ensuring safety during alcohol detoxification.
Choice D reason: A mental status exam assesses withdrawal severity, like delirium or hallucinations. Scientifically, it evaluates GABA and glutamate imbalances, guiding interventions. This identifies cognitive and psychological impairments, ensuring tailored care to stabilize neurobiological responses and support recovery from alcohol use disorder’s acute effects.
Choice E reason: Benzodiazepines manage withdrawal by enhancing GABA activity, reducing neural excitability. Scientifically, they prevent seizures and delirium tremens by countering glutamate-driven hyperactivity. Administering prescribed doses ensures safety, stabilizing neurobiological responses and supporting recovery during acute alcohol withdrawal phases effectively.
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