A family of a client who has a medical history of stroke, hyperlipidemia, and peptic ulcer disease arrives at the memory care clinic with concerns about their loved one. The family states that the client has experienced worsening memory loss and forgetfulness over the last 6 months. The nurse is concerned the client is experiencing vascular dementia, due to which of the following factors?
The client's history of hyperlipidemia, because hyperlipidemia can lead to dementia due to blocked neuron communication throughout the body.
The client's history of peptic ulcer disease, because peptic ulcer disease can lead to dementia due to the loss of nerve cells in the stomach.
The client's history of peptic ulcer disease, because peptic ulcer disease can lead to dementia by destroying neuron communication in the stomach.
The client's history of stroke, because stroke can lead to dementia due to changes in the blood vessels of the brain.
The Correct Answer is D
A. While hyperlipidemia can contribute to vascular damage, it primarily increases the risk of cardiovascular disease and stroke, rather than directly blocking neuron communication to cause dementia.
B. Peptic ulcer disease is not associated with dementia, and the loss of nerve cells in the stomach does not lead to cognitive decline.
C. Peptic ulcer disease does not cause dementia by impacting neuron communication in the stomach.
D. Vascular dementia is often caused by stroke due to reduced blood flow or damage to the blood vessels in the brain, leading to cognitive decline and memory loss.
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Correct Answer is ["C","D","E"]
Explanation
A. Restraints should not be used routinely for clients with seizure disorders, as they can lead to injury and are not recommended for seizure management.
B. A bite stick is not recommended during a seizure because it can cause injury to the client’s teeth and jaw.
C. Keeping an oxygen setup at the bedside is essential to provide supplemental oxygen if the client experiences difficulty breathing during or after a seizure.
D. Elevating the side rails when the client is in bed helps prevent falls and injuries during a seizure, providing a safer environment.
E. A suction setup at the bedside is important to clear secretions and prevent aspiration during a seizure, especially if the client has impaired swallowing or is at risk for aspiration.
Correct Answer is A
Explanation
A. A blood pressure of 80/40 mm/Hg indicates hypotension, which is a contraindication for administering furosemide. The medication can further lower blood pressure and increase the risk of adverse effects.
B. An oxygen saturation of 95% is within normal limits and does not indicate a need to withhold furosemide.
C. A serum sodium level of 140 mEq/L is normal and would not warrant withholding the medication.
D. A serum potassium level of 4.8 mEq/L is also normal and safe for furosemide administration, as the medication may cause potassium loss but does not require withholding if the level is within range.