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A person who is the caregiver of a parent with early-to-middle-stage Alzheimer disease is concerned about possible episodes of incontinence. What strategy should the nurse suggest?
- A. Limiting the patient's fluid intake to 1000 ml daily
- B. Discussing the use of an indwelling catheter with the physician
- C. Putting plastic coverings on the beds, upholstered chairs, and sofas
- D. Taking the patient to the bathroom at least every 2 hours when the patient is awake
Correct Answer: D
Rationale: The correct answer is D: Taking the patient to the bathroom at least every 2 hours when the patient is awake. This strategy helps prevent episodes of incontinence by ensuring the patient has regular opportunities to void. It promotes continence through scheduled toileting, maintaining the patient's dignity and preventing accidents.
Choice A is incorrect as restricting fluid intake can lead to dehydration and other health issues. Choice B is incorrect because indwelling catheters are not recommended for managing incontinence in Alzheimer's patients due to the risk of urinary tract infections. Choice C is incorrect as it only addresses the aftermath of incontinence, not the prevention of it.
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A 28-year-old female client was admitted 3 days ago after she ran nude through the streets shouting that she was the 'Queen of Hearts.' Since admission, the client remains delusional, shouts obscenities, and demonstrates loosely associated thoughts. Based on these data, the nurse should develop a nursing diagnosis of:
- A. Risk for violence
- B. Defensive coping
- C. Disturbed thought processes
- D. Impaired memory
Correct Answer: C
Rationale: The correct nursing diagnosis is "Disturbed thought processes" (C) because the client's behavior of being delusional, shouting obscenities, and demonstrating loosely associated thoughts indicates a disruption in their ability to think clearly and logically. This diagnosis reflects the client's cognitive dysfunction and disorganized thinking patterns.
Choice A (Risk for violence) is incorrect because the client's behavior does not directly suggest a risk for violence towards others or themselves.
Choice B (Defensive coping) is incorrect as the client's behavior is not indicative of using defensive mechanisms to cope with stress or anxiety.
Choice D (Impaired memory) is incorrect as the client's symptoms are more indicative of thought processing issues rather than memory deficits.
In summary, the client's presentation aligns closely with symptoms of disturbed thought processes, making it the most appropriate nursing diagnosis in this case.
A 35-year-old woman who is being interviewed by the advanced practice nurse indicates that she has few friends, fears criticism from others, and withholds information about her thoughts and feelings because she anticipates a negative reaction. Based on these data, the nurse suspects that Sarah may later be diagnosed as having:
- A. Borderline personality disorder
- B. Histrionic personality disorder
- C. Avoidant personality disorder
- D. Schizoid personality disorder
Correct Answer: C
Rationale: The correct answer is C: Avoidant personality disorder. This is because the woman's fear of criticism, avoidance of sharing thoughts/feelings, and limited social circle are indicative of social inhibition and feelings of inadequacy, which are key features of avoidant personality disorder.
A: Borderline personality disorder is characterized by unstable relationships, self-image, and emotions, as well as impulsivity and fear of abandonment.
B: Histrionic personality disorder involves attention-seeking behavior, emotions that are shallow and rapidly shifting, and the need to be the center of attention.
D: Schizoid personality disorder is marked by social detachment, limited emotional expression, and preference for solitary activities.
A man, aged 84 years, was stopped for going through a red light in a small town where he lives. He told the officer, 'It wasn't there yesterday.' He was unable to tell the officer his address and demonstrated labile mood, seeming pleasant one minute and angry the next. The officer took the man home to discuss his condition with the family and found that he has been wandering around the neighborhood, sometimes taking tools from people's garages, saying they belong to him. The family reluctantly agreed that he should go to the emergency department. What cardinal sign of Alzheimer's disease does this patient demonstrate?
- A. Agnosia.
- B. Apraxia.
- C. Aphasia.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Agnosia. Agnosia is the inability to recognize or interpret sensory information, such as objects, people, sounds, or shapes. In this case, the patient's inability to recognize the red light, his own address, and the ownership of tools indicates a problem with perception and recognition. This aligns with the symptoms of agnosia commonly seen in Alzheimer's disease.
Choices B and C are incorrect. Apraxia is the inability to perform purposeful movements, and aphasia is the loss of ability to understand or express speech. These symptoms are not the primary cardinal sign demonstrated by the patient in the scenario. Choice D, "None of the above," is also incorrect as the patient's symptoms align with the characteristics of agnosia.
The risk for developing the condition is about 50% only if both parents were carriers of the gene that predisposes the condition to their offspring.
- A. The risk is 25% if only one parent is a carrier.
- B. The risk is 50% if both parents are carriers.
- C. The risk is 75% if both parents are carriers.
- D. None of the above.
Correct Answer: B
Rationale: The correct answer is B. If both parents are carriers of a gene that predisposes a condition, each parent contributes one copy of the gene, resulting in a 50% chance that the offspring will inherit the gene from both parents, leading to a 50% risk of developing the condition. Choice A is incorrect because if only one parent is a carrier, the offspring has a 25% chance of inheriting the gene. Choice C is incorrect as the risk is not 75% when both parents are carriers, but rather 50%. Choice D is also incorrect as the risk is indeed 50% when both parents are carriers.
Disorders which are characterised by serious abnormalities in the developmental process, fall under the heading of pervasive developmental disorders (PDD) and are usually associated with impairment in several areas of development. From early infancy, some children will exhibit a spectrum of developmental impairments and delays that include which of the following?
- A. Social and emotional disturbances
- B. Intellectual disabilities
- C. Language and communication deficits
- D. All of the above
Correct Answer: D
Rationale: Pervasive Developmental Disorders (PDDs): Characterized by serious developmental abnormalities affecting social, intellectual, and communication skills.