The blood pressure and pulse rates for a client admitted last ...

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The blood pressure and pulse rates for a client admitted last night with a compound fracture of the
  femur sustained in a fall while intoxicated, are recorded as follows:
  admission 2 AM, 122/80 mm Hg and 72 beats/min
  4 AM, 126/78 mm Hg and 76
 
  beats/min
  6 AM, 124/80 mm Hg and 72 beats/min
  8 AM, 132/88 mm Hg and 80 beats/min
  10 AM, 148/88 mm Hg and 96 beats/min
  The priority action for the nurse to take is to
  a. encourage the client to drink plenty of liquids.
  b. obtain a clean-catch urine sample.
  c. place the client in a vest-type restraint.
  d. notify the physician.

Question 2

A man, aged 84 years, was stopped for going through a red light in a small town where he has lived
 all his life. 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 individual to his home to discuss his condition with the family and found that he lives with his wife, who is legally blind. She stated He's my eyes and I'm his mind.. She also related that her husband wanders around the neighborhood, sometimes taking tools from people's garages, saying they belong to him. She reluctantly agreed that he should go to the emergency department for
 evaluation. He was diagnosed with Alzheimer's disease. The cardinal sign of Alzheimer's disease demonstrated by the client is

a. aphasia.
 b. apraxia.
 c. agnosia.
 d. memory impairment.

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Answer to Question 1

D
Elevated pulse and blood pressure may indicate that the client is going into withdrawal delirium and
that additional sedation is warranted. None of the other options takes into account the possible need
for sedation. Options B and C: No indication is present that the client may have a urinary tract
infection or is presently in need of restraint. Option A is too nonspecific. Overhydration may bring
on its own set of problems.

Answer to Question 2

D
Of the cardinal signs of Alzheimer's disease, the client is presently demonstrating only mnemonic
disturbance, or memory loss. Option A: Aphasia refers to the loss of language ability. Option B:
Apraxia refers to the loss of purposeful movement. Option C: Agnosia refers to the loss of sensory
ability to recognize objects.