The nurse is caring for residents on an Alzheimer's unit. What assessment findings indicate that a patient is in early stages of the disease?
a. Increased intracranial pressure (ICP)
b. Forgetfulness
c. Combativeness
d. Agitation
ANS: B
The signs and symptoms of Alzheimer's disease are typically broken down into three stages. The early stage, stage one, lasts 2 to 4 years and is characterized by increasing forgetfulness. Behavior changes occur later, and increased ICP is not associated with Alzheimer's.
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A nurse in the medical-surgical unit has a newly admitted patient who is oliguric; the acute care nurse practitioner orders a fluid challenge of 100 to 200 mL of normal saline solution over 15 minutes. The nurse is aware this intervention will help:
A) Distinguish hyponatremia from hypernatremia B) Evaluate pituitary gland function C) Distinguish reduced renal blood flow from decreased renal function D) Provide an effective treatment for hypertension-induced oliguria
Which temperature indicates a pyrexia?
a. 37.5–38.5°C b. 36.0–37.5°C c. 37.0–38.0°C d. 38.0–39.0°C
The nurse is assessing a cognitively impaired older adult client and observes a leaking of liquid stool from the rectum. The nurse's initial intervention for this client is to:
1. Determine if the client has been eating sufficiently, especially fiber-rich foods 2. Determine how long it has been since the client had a normal-size, formed stool 3. Perform a digital examination of the rectum to determine the presence of stool 4. Call the health care provider to get a prescription for an antidiarrheal medication
Care for a patient with a fracture involves all of the following goals except
A. controlling pain. B. preventing or reducing edema. C. maintaining good alignment of fractured bone. D. enhancing range of motion of fractured bone.