Nokea
When providing community healthcare teaching regarding the early warning signs of Alzheimer's disease,which signs should the nurse advise family members to report? (Select all that apply.)
- A. Becoming lost in a usually familiar environment.
- B. Difficulty performing familiar tasks.
- C. Losing sense of time.
- D. Misplacing car keys.
- E. Problems with performing basic calculations.
Correct Answer: A,B,C,E
Rationale: The correct answers are A, B, C, and E. A: Becoming lost in a familiar environment can indicate spatial disorientation. B: Difficulty performing familiar tasks may signal cognitive decline. C: Losing sense of time is a common early sign of Alzheimer's. E: Problems with basic calculations indicate cognitive impairment. Incorrect answers: D: Misplacing car keys is more indicative of normal forgetfulness. F and G: Not applicable. In summary, the correct choices focus on cognitive and spatial changes, while the incorrect choices are more related to normal memory lapses.
You may also like to solve these questions
A nurse in the acute mental health unit is admitting a new client with an eating disorder. The nurse is aware that which of the following are considered comorbidities of eating disorders? (Select all that apply.)
- A. Anxiety
- B. Depression
- C. Obsessive-compulsive disorder
- D. Schizophrenia
- E. Breathing-related sleep disorder
Correct Answer: A,B,C
Rationale: The correct answer is A, B, and C. Anxiety, depression, and obsessive-compulsive disorder are commonly seen as comorbidities in individuals with eating disorders. Anxiety and depression are often present due to the psychological stress and emotional turmoil associated with the eating disorder. Obsessive-compulsive disorder can manifest in obsessive thoughts about food, weight, and body image, as well as compulsive behaviors related to eating and exercise. Schizophrenia and breathing-related sleep disorder are not typically associated with eating disorders, making choices D and E incorrect. It is essential for the nurse to be aware of these comorbidities to provide holistic care to the client.
A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address?
- A. I haven't gotten my period yet, and all my friends have theirs.
- B. There's a big pimple on my face, and I worry that everyone will notice it.
- C. My parents treat me like a baby sometimes.
- D. None of the kids at this school like me, and I don't like them either.
Correct Answer: D
Rationale: The correct answer is D because the adolescent's statement indicates feelings of social isolation and potential difficulty in forming relationships with peers. Addressing this issue is crucial to prevent further emotional distress. Choice A is common for adolescents and does not raise immediate concerns. Choice B is a common concern related to body image. Choice C may indicate normal parent-child dynamics.
A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following nursing actions is the highest priority?
- A. Determining the cause of the client's anxiety
- B. Identifying the client's coping skills
- C. Protecting the client from injury to himself
- D. Ensuring that the client feels safe
Correct Answer: C
Rationale: The correct answer is C: Protecting the client from injury to himself. This is the highest priority because during a crisis intervention for acute anxiety, the client may be at risk of harming themselves. Ensuring their safety is crucial before addressing other needs. Option A is important but not the highest priority in this acute situation. Option B is relevant but not as urgent as ensuring safety. Option D is also important, but physical safety takes precedence over emotional safety.
A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?
- A. DIC is characterized by an elevated platelet count.
- B. DIC is caused by abnormal coagulation involving fibrinogen.
- C. DIC is controllable with lifelong heparin usage.
- D. DIC is a genetic disorder involving a vitamin K deficiency.
Correct Answer: B
Rationale: Correct Answer: B - DIC is caused by abnormal coagulation involving fibrinogen.
Rationale: DIC is a complex disorder characterized by widespread activation of coagulation leading to both excessive clot formation and consumption of clotting factors, including fibrinogen. This results in abnormal coagulation and fibrinolysis, leading to both bleeding and clotting throughout the body. Elevated platelet count is not a feature of DIC; instead, platelets are consumed in the process. Lifelong heparin usage is not a standard treatment for DIC, as it is a condition that requires specific management based on the underlying cause. DIC is not a genetic disorder but rather an acquired condition often triggered by severe infections, sepsis, trauma, or other critical illnesses. Vitamin K deficiency is associated with certain clotting factor deficiencies but is not the primary cause of DIC.
A nurse is caring for a client diagnosed with schizophrenia. The client states,Did you know that I am engaged to the Prince of England? The nurse should document that the client is experiencing which of the following types of delusions?
- A. Persecution
- B. Erotomanic
- C. Somatic
- D. Control
Correct Answer: B
Rationale: The correct answer is B: Erotomanic delusion. This type of delusion involves the false belief that someone, typically of higher status or unreachable, is in love with the individual. In this case, the client believes they are engaged to the Prince of England, indicating an erotomanic delusion. Choice A: Persecution delusion involves believing one is being targeted or mistreated. Choice C: Somatic delusion involves beliefs about bodily functions. Choice D: Control delusion involves beliefs about external control. These are not applicable in the scenario described.