The nurse is providing care for a client who was placed in a halo brace 2 days ago because of a spinal cord injury. Which assessment is the first priority of the nurse?

Loosen all of the connections on the vest to assess the skin

Ask about the client's ability to perform range of motion to legs

Ask how the client is able to reposition self in bed

Assess the pin sites

Answer and Explanation

The Correct Answer is D

Choice A Rationale: Loosening all of the connections on the vest to assess the skin is not the first priority and may compromise the stability of the halo brace.

Choice B Rationale: Asking about the client's ability to perform range of motion to legs is important but may not be the first priority.

Choice C Rationale: Asking how the client is able to reposition self in bed is important but may not be the first priority.

Choice D Rationale: Assessing the pin sites is the first priority in caring for a client with a halo brace, as complications related to pin site infections or issues can have significant consequences. Pin site care and assessment are crucial to prevent infections and complications.

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Correct Answer is D

Explanation

Choice A Rationale: Fecal incontinence is not typically associated with mild Alzheimer's disease but may occur in later stages.

Choice B Rationale: Urinary incontinence can occur in Alzheimer's disease, but it is not specific to the mild stage.

Choice C Rationale: Inability to smile is not a typical manifestation of Alzheimer's disease but may be related to facial muscle weakness or other factors.

Choice D Rationale: Being able to drive to familiar places is consistent with the early stage of Alzheimer's disease, where clients may still have some independence and ability to perform routine tasks.

A. Sedatives B. Antipsychotics C. Cholinesterase inhibitors D. Serotonin Reuptake inhibitors

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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The nurse is providing care for a client who was placed in a halo brace 2 days ago because of a spinal cord injury. Which assessment is the first priority of the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse caring for the client with Alzheimer's documents that the client is in the early stage of Alzheimer's. Which findings are consistent with mild Alzheimer's disease?

Correct Answer is D

Explanation

A client with Alzheimer's is having increased behavioral issues that have become a safety concern for the client and others. Which of the following medications will the nurse discuss with the physician for inclusion in the client's care plan?

Correct Answer is B

Explanation

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