HESI Registered Nurse EXIT Practice Exam

What condition in a client with dementia requires immediate nurse intervention instead of delegation?

1. Change in respiratory rate of 2 breaths increase.

2. Increase in heart rate by 10 beats.

3. Minimal responsiveness to voice and touch.

4. Blood pressure decrease of 8 mmHg systolic.

The correct answer is: Minimal responsiveness to voice and touch.

In clients with dementia, any significant change in their level of responsiveness can indicate a potential medical emergency. Minimal responsiveness to voice and touch suggests that the client may be experiencing worsening neurological function or a critical underlying condition, such as infection, metabolic imbalance, or stroke. This may necessitate immediate assessment and intervention to ensure the safety and well-being of the patient. Recognizing a decline in responsiveness can guide the nurse to perform further evaluations, such as checking vital signs, glucose levels, or neurologic assessments, and to implement appropriate interventions without delay. Timely action is crucial because the underlying cause of a decrease in responsiveness could rapidly deteriorate the patient’s condition if not addressed promptly. While changes in respiratory rate, heart rate, or blood pressure are important observations that warrant attention, they may not necessitate immediate hands-on intervention compared to a notable decline in a patient's level of consciousness or responsiveness. In those cases, further monitoring and possible delegation of tasks to other staff members could be appropriate once the immediate risks are assessed.