Boyd- Elder Assessment, Dementia, & Delirium (ch 36 & 37)

A nurse is caring for a client with delirium who is experiencing illusions. What environmental conditions should the nurse arrange for this client? -provide a well-lit room without glare or shadows and limit noise -light the room brightly around the clock and awaken hourly to check mental status -keep the room shadowy with soft lighting around the clock, and keep a radio on continuously -have the client sit by the nurse's desk while awake in a room with the television on

provide a well-lit room without glare or shadows and limit noise

A client was admitted to the intensive care unit after a motor vehicle accident. The client sustained a right parietal injury, resulting in an acute confusional state or delirium. The client reports that there are "bugs crawling around" on the arms. The nurse understands this as: -tactile hallucinations from delirium. -a predisposition to such episodes early in the morning. -preexisting schizophrenia. -increasing brain damage and poor prognosis.

tactile hallucinations from delirium.

The nurse working on a unit for older adults suffering from mental health disorders realizes that many things other than a mental condition can affect mental status in the elderly. These include which of the following? Select all that apply. Sepsis Hypoxia Acid-base imbalance Spirituality Dehydration Medications

Acid-base imbalance Dehydration Hypoxia Sepsis Medications

A nurse identifies an unintentional weight loss of 5 kg during a physical assessment of an older adult. Identifying a mental health problem would be indicated or suggested if client response is ... Client's reduced pleasure in eating as difficulty to smell food Difficulty swallowing Afraid to eat as the food is poisoned A decreased appetite

Afraid to eat as the food is poisoned

A nurse is using the Neuropsychiatric Inventory to assess an older adult client with dementia. Which behavior would the nurse most likely assess when using this tool? Select all that apply. Depression Aggression Apathy Euphoria Inhibition

Aggression Inhibition Apathy Euphoria

A client is diagnosed with Alzheimer's disease. While assessing the client, the nurse notes that the client has trouble identifying objects such as a key and spoon. The nurse would document this as what? Agnosia Disturbance of executive function Aphasia Apraxia

Agnosia

A client with dementia is unable to recognize ordinary objects, such as a pen or notebook. The nurse recognizes this symptom as ... Amnesia Apraxia Agnosia Aphasia

Agnosia

Which of the following terms describes an inability to recognize or name objects despite intact sensory abilities? Executive functioning disturbance Agnosia Apraxia Aphasia

Agnosia

A client has been newly diagnosed with delirium. The nurse knows that the primary sign of delirium includes which of the following? Inability to fulfill role Impaired socialization Disturbed sleep-wake cycles An altered level of consciousness

An altered level of consciousness

Older adults who have taken a drug from which medication classification may have symptoms of tardive dyskinesia? Anti-anxiety medications Anticonvulsants Antipsychotics Antidepressants

Antipsychotics

A client has been diagnosed with dementia and is exhibiting several cognitive disturbances. Which of the following terms is used to describe the inability to execute motor functioning despite intact motor abilities? Executive functioning Apraxia Agnosia Aphasia

Apraxia

Assessment of an older adult reveals the inability to execute a voluntary movement despite normal muscle function. The nurse would document this finding using which term? Dysphagia Dyslexia Ataxia Apraxia

Apraxia

Which term is used to describe the inability to execute motor functioning, despite intact motor abilities? Apraxia Executive functioning Aphasia Agnosia

Apraxia

When conducting a nursing assessment of a client experiencing moderate cognitive dysfunction, the nurse can best prepare for an effective interview by ensuring what? -Asking a family member to be present during the assessment -Sitting beside the client and using touch to be supportive -Breaking up the assessment into several short periods rather than a continuous one -Being sure the client is well rested before beginning the interview

Asking a family member to be present during the assessment

Which of the following drug classifications is avoided due to the fact that they may worsen delirium? Benzodiazepines Nonbenzodiazepines Vitamins Antipsychotics

Benzodiazepines

A nurse working with elderly clients knows the importance of adequate fluid intake and increasing fiber consumption to help prevent constipation. However, the nurse also is aware that increased fiber may cause which of the following side effects in these clients? Select all that apply. Excessive gas Infrequent urination Bloating Increased appetite Decreased taste buds

Bloating Excessive gas

A client has vascular neurocognitive disorder. When teaching the family about the cause of this disorder, which would the nurse expect to integrate into the explanation? Blood flow in the vessels to the brain are blocked. Strands of protein are tangled together. Acetylcholine production is decreased. Fragments mix with molecules to make plaques in the brain.

Blood flow in the vessels to the brain are blocked.

A nurse assesses an older adult in the clinic who comes in for his follow-up appointment with the smell of alcohol on his breath. The nurse may consider the use of the ... CAGE questionnaire Functional assessment Mini mental status BEHAVE-AD rating scale

CAGE questionnaire

A nurse is providing care to a client with dementia who is hyperactive. A diet high in which of the following would be most appropriate to include in the nutritional plan for this client? Select all that apply. Carbohydrates Fat Protein Potassium Fiber

Carbohydrates Protein

Which client population has the greatest number of suicide deaths in the older age group? Caucasian women African-American women Caucasian men Asian-American men

Caucasian men

When interviewing a client, it is important for the nurse to understand that deafness can be mistaken for which of the following impairments? Perceptual deficit Cognitive dysfunction Social impairment Low intelligence

Cognitive dysfunction

A nurse caring for an elderly client knows that quality of life is important to people of all age groups. Many older adults, however, define quality of life as which of the following? Contentment with how they have lived Retirement benefits Material possessions Physical health

Contentment with how they have lived

Which of the following is the best validated scale for clients with dementia? Geriatric Depression Scale (GDS) Cornell Scale for Depression in Dementia (CSDD) Hamilton Rating Scale Rating Anxiety in Dementia (RAID)

Cornell Scale for Depression in Dementia (CSDD)

An older adult client with a history of seizures is prescribed antipsychotic medication as part of the treatment plan for mental illness. When teaching the client about the medication. the nurse would explain that the medication has which effect on seizure threshold? Decrease Increase Double No effect

Decrease

An 80-year-old is brought to the clinic by the client's spouse. The client has a history of peripheral vascular disease and type 2 diabetes. The spouse states that the client hasn't seemed to be normal for the preceding few days, noting that the client has been lethargic and mildly confused at times and has been incontinent of urine. The spouse reports that the client's blood glucose levels have been elevated. The nurse considers which as the most likely explanation for the client's change in mental status? -Depression related to declining health -Dementia related to advancing age -Delirium related to underlying medical problem -Transient ischemic attacks related to vascular disease and diabetes

Delirium related to underlying medical problem

The neuropsychiatric Inventory (NPI) was developed in 1994 to assess behavior problems associated with which disorder? Depression Dementia Delirium Schizophrenia

Dementia

The nurse can distinguish delirium from dementia by knowing which of the following? -Dementia has an acute onset and can be resolved. -Dementia has a gradual onset and is progressive in course. -Delirium has a gradual onset and can be resolved. -Delirium has an acute onset and is progressive in course.

Dementia has a gradual onset and is progressive in course.

The nurse is encouraging a group of clients with dementia to join in upper body range of motion exercises using light dumbbells. Which technique will most likely result in the greatest amount of participation? -Show an instructional video just prior to the activity. -Describe the exercise immediately before performing it. -Perform the same routine daily to avoid the need for repeated instruction. -Demonstrate the exercises while clients simultaneously perform them.

Demonstrate the exercises while clients simultaneously perform them.

The nurse is attending a seminar on prevention of suicide. The presenter is discussing risk factors for suicide, stating that which of the following is the greatest risk factor? Substance abuse Depression Anxiety Stress

Depression

Which of the following is the greatest risk factor for suicide in older adults? Bereavement Delirium Dementia Depression

Depression

A group of nurses working in the local long-term care facility is reviewing information about mental health problems in older clients. The nurses demostrate understanding of the information when they list which problem as being most common in older adults? Select all that apply. Anxiety disorders Dementia Bulimia Diabetes Depression

Depression Anxiety disorders Dementia

A major barrier to an elderly person seeking adequate mental health care may be due to the myth that says what? -Often healthcare professionals tend to exaggerate the effects of mental problems. -Older people too often seek health assistance, particularly for mental or emotional disorders. -Depression, confusion, memory loss, and other mental or emotional problems are simply part of normal aging. -Elderly clients tend to get frustrated and confused negotiating care within the array of mental health services available.

Depression, confusion, memory loss, and other mental or emotional problems are simply part of normal aging.

A client diagnosed with Alzheimer's disease (AD) has decided that he is more comfortable naked than in clothes. This would be documented as which of the following? Bradykinesia Hypersexuality Cognitive reserve Disinhibition

Disinhibition

During the change of shift report in the intensive care unit, the nurse learns that a client has developed signs of delirium over the past 8 hours. Which behavior documented in the nursing notes would be consistent with delirium? Unable to identify a water pitcher Unable to transfer to sitting position Disoriented to person Difficulty with verbal expression

Disoriented to person

Which type of therapy involves shifting the client's attention and energy to a more neutral topic? Distraction Reminiscence therapy Time away Going along

Distraction

Clients taking some antipsychotic medications can have the side effect of orthostatic hypotension. Which of the following can occur from this side effect? Select all that apply. Headache Unsteady gait Flushing Falls Dizziness

Dizziness Unsteady gait Falls

A nurse assessing a client's social support should ask the following ... How many times a week do you go grocery shopping? What is the proximity of the closest government office? Do you have any one special person you could call if you needed help? Where do your children live?

Do you have any one special person you could call if you needed help?

To assist in resolving polypharmacy issues in older adults, nurses are encouraged to implement the "all" system. This refers to what? -Encouraging all clients to bring all their medications to all physician visits -Encouraging all clients to tell all healthvcare providers about all over-the-counter medications -Encouraging all clients to tell all physicians about all of their medications -Encouraging all clients to bring all over-the-counter medications to all physician visits

Encouraging all clients to bring all their medications to all physician visits

A client with Alzheimer's disease in the intensive treatment unit repeatedly tries to go into other clients' rooms to nap during the day. The most appropriate nursing intervention for this client is what? Escorting the client to the client's room for napping Explaining to the client why this cannot be tolerated Allowing the client to nap in an empty room Suggesting that daytime napping be decreased

Escorting the client to the client's room for napping

A nurse interviewing an elderly client with a mental health disorder uses a lower voice pitch for which of the following reasons? -High-pitched voices often denote sarcasm, which can insult patients. -High-pitched sounds are lost with presbycusis. -High-pitched voices are irritating to the mentally ill. -High-pitched voices are overly authoritarian and can scare vulnerable patients.

High-pitched sounds are lost with presbycusis.

A nurse is assessing the mental status of an older adult. Which change would the nurse need to keep in mind as affecting the client's mental status? Select all that apply. Hypothyroidism Hypoxia Electrolyte changes Fluid overload Infection

Hypothyroidism Electrolyte changes Hypoxia Infection

During an assessment of an older adult, the nurse must identify chronic health problems in order to ... -Provide treatment for physical problems not addressed otherwise -Use information for cognitive testing -Link direct result of physical problems to mental health problems -Identify client management of mental health problems

Identify client management of mental health problems

During an assessment of an older adult, a nurse must identify chronic health problems in order to ... -Identify which could affect mental health problems -Provide treatment for physical problems not addressed otherwise -Link direct result of physical problems to mental health problems -Use information for cognitive testing

Identify which could affect mental health problems

A nursing instructor is teaching students about changes seen in the elderly. Which of the following functions does the instructor tell the students do not change with age? Select all that apply. Sensory function Immune function Pulmonary function Intellectual function Capacity for change

Intellectual function Capacity for change

The nurse assesses an older adult client's blood pressure to obtain a baseline, and monitor fluctuations because psychiatric medications frequently cause ... Urinary retention Orthostatic hypotension Decreased appetite Constipation

Orthostatic hypotension

A client has experienced a gradual flattening of affect, confusion, and withdrawal and has been diagnosed with Alzheimer's disease. Which additional findings would the nurse most likely assess? -Transient blindness, slurred speech, and weakness -Personality change, wandering, and inability to perform purposeful movements -Uncharacteristic use of illicit substances and alcohol -Tremors, unsteady gait, and transient paresthesias

Personality change, wandering, and inability to perform purposeful movements

While the nurse is assessing functional status, the client asks what the nurse means by instrumental activities of daily living (IADLs). Which of the following are considered IADLs? Select all that apply. Shopping Using the telephone Using transportation Toileting Bathing

Shopping Using transportation Using the telephone

The nurse receives a report that a 75-year-old client is recovering from surgery. During the shift, the nurse notes that the client is forgetful and restless. Several times, the client calls the nurse the name of the client's daughter. The nurse interprets this behavior as what? Normal for the first postoperative day Normal, given the client's age Signs of early Alzheimer's disease Signs of delirium

Signs of delirium

A client is being evaluated for decline in cognitive function. The client's wife asks the nurse to explain the term dementia to her. The nurse bases her response on the knowledge that dementia is which of the following? Often reversible if diagnosed and treated quickly A primary brain pathology Secondary to a medical condition Does not always affect memory

A primary brain pathology

The adult child of a client with dementia has been the primary caregiver for 5 months. The adult child expresses to the nurse, "At times it is so overwhelming! I feel I do not have a life anymore!" Which is the most helpful response by the nurse? -"Here is the number of a caregivers' support group. How do you think you would feel talking with others in the same situation?" -"Are you saying you don't want to care for your parent anymore?" -"Your parent really appreciates what you do. You are the best one to care for your parent." -"I know it is really hard. It takes a lot of work and you are doing such a good job."

"Here is the number of a caregivers' support group. How do you think you would feel talking with others in the same situation?"

A 73-year-old client has been brought to the emergency department by the client's adult children due to abrupt and uncharacteristic changes in behavior, including impairments of memory and judgment. The subsequent history and diagnostic testing have resulted in a diagnosis of delirium. Which teaching point about the client's diagnosis should the nurse provide to the family? -"For many older adults, this is considered to be just a normal part of the aging process." -"Delirium can be caused by a wide variety of factors but most of the changes in behavior and personality are permanent." -"The treatment that the care team will likely provide is simple rest, which will probably bring about a return to normal." -"If the underlying cause of delirium is identified and treated, most people return to their previous level of functioning."

"If the underlying cause of delirium is identified and treated, most people return to their previous level of functioning."

The adult child of a client with dementia asks the nurse if the client will ever be able to live independently again. Which would be the most appropriate response by the nurse? -"The client's confusion is a temporary complication of the physical illness and should subside when the illness gets better." -"With early treatment, mild dementia can be reversed. It may be possible." -"Symptoms of dementia gradually get worse. Unfortunately, the client will not be independent again." -"You sound like you aren't ready for the client to be dependent on caregivers."

"Symptoms of dementia gradually get worse. Unfortunately, the client will not be independent again."

An 80-year-old client with Alzheimer's disease is prescribed donepezil. Which teaching points should the nurse provide to the client's spouse about the new medication? -"It's important to closely follow the administration schedule for this drug if it is to make the client recover." -"The drug won't improve the client's symptoms but it will make the client much more compliant and easier to manage." -"This drug will help the client sleep much better at night and stay awake during the day." -"The drug won't cure the client's Alzheimer's, but it has the potential to slow down the progression of the disease."

"The drug won't cure the client's Alzheimer's, but it has the potential to slow down the progression of the disease."

A 35-year-old client is delirious after being lost in the woods for several days and becoming severely dehydrated. At 9 p.m. the client tells the nurse to get the client's clothes because the client has to get home to the client's family. Which response by the nurse is most therapeutic? -"It's time to sleep now; you can see your family in the morning." -"Your family is fine. You need to take care of yourself now." -"You're in the hospital. You did not drink for several days, but you're getting better now." -"We don't have your clothes; they are at home. You'll be going home when you recover."

"You're in the hospital. You did not drink for several days, but you're getting better now."

When working with an elderly client who has a mental disorder, the nurse recognizes the importance of interviewing the client as well as his or her family members. The main reasons for talking to family members is for which of the following purposes? Select all that apply. -Interviewing relatives gives the nurse an opportunity to evaluate caregivers themselves. -Standard nursing policy requires interviewing family. -Family members will always give a better assessment than patients. -Such involvement makes family feel needed and loved. -Family members often notice changes that clients fail to notice in themselves.

-Family members often notice changes that clients fail to notice in themselves. -Interviewing relatives gives the nurse an opportunity to evaluate caregivers themselves.

A nurse is reading a journal article about medication use and the older adult. The nurse demonstrates understanding of the article by identifying which issue related to pharmacotherapy represents the greatest possible risk to an older client's health? -Problems administering medications secondary to swallowing difficulties -Polypharmacy -Older adults' decreased ability to metabolize and excrete medications -Older adults' use of alternative remedies

-Polypharmacy

Which of the following clients would have an increased risk for delirium? -Elderly woman with abdominal pain -3-year-old child with a temperature of 103.2 °F -Middle-aged woman newly diagnosed with multiple sclerosis -Young adult male with gastroenteritis and dehydration

3-year-old child with a temperature of 103.2 °F

Late-onset depression typically occurs after which age? 70 50 60 40

60

An older adult is brought to the clinic by the client's child who reports that the client has been demonstrating unexplained behavior and personality changes. The nurse assesses the client, paying special attention to which area? Experience of chronic pain History of abuse Family supports Past experiences with losses

Experience of chronic pain

Constipation is a gastrointestinal problem seen in older adults. The nurse must be aware of which serious complication of constipation? Diarrhea Excessive gas production Bloating Fecal impaction

Fecal impaction

Which of the following are considered indications of high risk for committing suicide in the older adult? Select all that apply. Burden to family Married Firearms in the home Social Isolation Active lifestyle

Firearms in the home Social Isolation Burden to family

A client with Alzheimer's disease is confused and mumbling incoherently and rambling. To help redirect the client's attention, the nurse should encourage the client to ... Put together a 250-piece puzzle Perform an aerobic exercise Play chess with another client Fold towels

Fold towels

When describing the dementia associated with Huntington disease, a nurse understands that the problems involving behavior and attention arise from a disruption in which lobe of the brain? Temporal Parietal Frontal Occipital

Frontal

A screening tool for depression that is designed as a self-administered test with use of "yes/no" answers is referred to as ... CSDD HAM-D GDS Mini mental status examination

GDS

A client with dementia is having difficulty clearly communicating about physical needs. When teaching the caregiver about ways to assist the client in meeting physical needs, which instruction would the nurse most likely include? Keep a record of emotional outbursts. Give acetaminophen if the client appears uncomfortable. Keep a record of bowel movements. Ensure environmental noise for stimulation.

Keep a record of bowel movements.

Depression in older adults is overlooked by primary care providers as a result of the older adult's ... Frequent emergency department visits Minimal contact with primary care providers Less likely to report feeling sad or worthless Mostly living in extended supportive families

Less likely to report feeling sad or worthless

A client with delirium exhibits signs and symptoms of hypokinetic delirium. Which of the following would the nurse most likely assess? Select all that apply. Marked excitability Hallucinations Sleepiness Lethargy Apathy

Lethargy Apathy Sleepiness

An older person came to the clinic for a pre-op appointment accompanied by the client's daughter. The daughter looks firmly at the mother and then says to the nurse, "My mother does not need the surgery." The client who is sitting toward the back of the exam room then says quietly, "No, I don't need this surgery." Which action by the nurse would be most appropriate? -Listen to the daughter but proceed with pre-op orders -Listen to the client and cancel the surgery -Explore with the social worker the next course of action -Give them time to discuss the pros and cons of the surgery

Listen to the client and cancel the surgery

The most effective intervention for clients with delirium is which of the following? -Promoting rest with PRN medications -Managing environmental stimuli -Providing activities for distraction -Giving detailed explanations

Managing environmental stimuli

Which is the most effective intervention for clients with delirium? -Giving detailed explanations -Managing environmental stimuli -Providing activities for distraction -Promoting rest with PRN medications

Managing environmental stimuli

Which of the following is the most consistent and dramatic cognitive impairment seen in dementia? Language Executive functioning Memory Visuospatial

Memory

When comparing dementia and dementia syndrome, the nurse understands that dementia is characterized by which of the following? Short duration of symptoms Mood fluctuations Rapid onset Focus on disabilities

Mood fluctuations

The nurse is caring for a client with Alzheimer's disease. The nurse observes that the client's pacing and mumbling to himself increase at mealtime and shift change. Which of the following interventions should the nurse implement first? -Administer an antianxiety drug such as lorazepam (Ativan) at these times. -Move the client to a quieter area during these times. -Keep unit activity to a minimum. -Explain the unit routine and the reasons for increased activity to the client.

Move the client to a quieter area during these times.

The nurse is caring for a client with Alzheimer's disease. The nurse observes that the client's pacing and mumbling to the self increase at mealtime and shift change. Which intervention should the nurse implement first? -Explain the unit routine and the reasons for increased activity to the client. -Administer an antianxiety drug such as lorazepam at these times. -Keep unit activity to a minimum. -Move the client to a quieter area during these times.

Move the client to a quieter area during these times.

Assessing an older adult, the nurse learns that one factor contributing to the client remaining mentally healthy and living alone is the individual's ... Pet Proximity to grocery store Pain threshold Availability of hospital emergency departments in close proximity

Pet

The nursing supervisor in an extended care facility is managing the environment to best help the clients with dementia. Which should the nurse include in planning the living environment? -Provide a buffet-style menu with many food choices. -Plan for the same caregivers to provide care to individuals as much as possible. -Assign peer-led exercise activities on a daily basis. -Open the windows and doors to allow fresh air to circulate through the environment.

Plan for the same caregivers to provide care to individuals as much as possible.

A common problem seen in older adults living in nursing homes is dysphagia. Dysphagia can lead to which of the following complications? Select all that apply. Stroke Asphyxiation Pneumonia Malnutrition Pulmonary emboli

Pneumonia Asphyxiation Malnutrition

Which of the following is accurate with regard to suicide in older adults? Rates are higher among older white women Rates decrease with age Rates increase with age Rates are higher among married men ages 42 to 77 years

Rates increase with age

Assessment of an older adult reveals that the client is experiencing loneliness. When developing the plan of care for this client, which intervention would be most appropriate for the nurse to include to address this problem? Referring client to the nearest senior center Identifying the nearest nursing home Arranging family visits Planning a vacation for client to visit friends

Referring client to the nearest senior center

Which nursing diagnosis would be the priority for the client experiencing acute delirium? -Risk for self-mutilation related to confusion and cognitive deficits -Acute confusion related to delirium of known/unknown etiology -Risk for injury related to confusion and cognitive deficits -Fall precautions related to acute confusion

Risk for injury related to confusion and cognitive deficits

A 72-year-old woman states that she has trouble sleeping and that her appetite has declined. She also tells the nurse that she hasn't been getting out much lately. Findings from her physical examination and laboratory studies are normal. Based on these data, the nurse would do which of the following? -Tell her that her symptoms are associated with the normal aging process, but that exercise will help. -Screen her for depression. -Schedule a follow-up appointment in 3 months to monitor her health. -Collaborate with the physician to have a sleeping medication ordered and suggest that she get more exercise to stimulate her appetite.

Screen her for depression.

The client is 42 years old, married, and has two children, ages 16 and 18. The client is also caring for the client's parent, who is in the late stages of Alzheimer's disease. The nurse would want to assess the client for what? Signs of stress Signs of dominance Likelihood to engage in elder abuse Early signs of Alzheimer's disease

Signs of stress

A nurse is conducting an geropsychiataric assessment of an older adult client. Which component would the nurse evaluate when assessing the client's social domain? Select all that apply. Spiritual assessment Risk assessment Legal information Mental status examination Quality of life

Spiritual assessment Legal information Quality of life

Which of the following is the priority for the older adult experiencing a mental health problem? Ability to complete ADLs Appropriate shelter Suicide assessment Social support

Suicide assessment

A psychiatric technician greets an older adult client by saying, "Hello, Bob. My name is Matt. I have to take some information from you. First, how many years young are you?" The nurse overhearing this exchange should do what? -Take the technician aside to explain that his words are inadvertently disrespectful. -Do nothing. Even though the technician's approach is a little too familiar, the client should be able to understand that the technician is trying to be respectful. -Interrupt the technician to point out that he should address the client by his surname. -Do nothing. The technician's friendly manner will put the client at ease.

Take the technician aside to explain that his words are inadvertently disrespectful.

A nurse is assessing an older adult who has been treated with typical antipsychotics. The nurse should consider assessing for symptoms of ... Urinalysis Cognition Tardive dyskinesia Diabetes

Tardive dyskinesia

The client has early Alzheimer's disease. When asked about family history, the client relates that the client has two children who are both grown and who visit the client around the holidays each year. The nurse subsequently discovers that the client has one child who is currently assigned overseas and who has not been home for 2 years. Which would best describe the client's behavior? -The client is showing signs of agnosia in that the client is unable to name the client's children. -The client demonstrates aphasia when discussing the client's children. -The client is confused about the client's children and needs refocusing. -The client is confabulating, most likely to cover for memory deficit.

The client is confabulating, most likely to cover for memory deficit.

A nurse working in an assisted living facility is holding an inservice for the nursing assistants. The nurse reviews common behaviors associated with cognitive deterioration associated with dementia. Which would cause the nurse to know that the assistants correctly understood if it were expressed during a posttest? -The clients should know when to come to the dining room for meals. -The clients may not recognize their family when they come to visit. -The clients who are ambulatory can still carry out activities of daily living independently. -The clients should be able to ask us for items they need.

The clients may not recognize their family when they come to visit.

The diagnosis of delirium is supported when the nurse notes which in the client? -The client repeatedly asks where the client is and attempts to drink the water in a flower vase -The is convinced that the client sees "hundreds" of bugs and is not always oriented to time and place -The client spends much of the day sleeping in the dayroom and usually denies being hungry -The client responds to most assessment questions with "I don't know" and appears apathetic

The is convinced that the client sees "hundreds" of bugs and is not always oriented to time and place

The nurse preparing an educational program on dementia should include which information? -Dementia has many different causes -Delirium involves progressive deterioration of intellect -Delirium is the most debilitating condition seen in the older population -The onset of symptoms of dementia is gradual

The onset of symptoms of dementia is gradual

A nurse assessing an older adult for suicide should assess for high risk factors such as ... Frequent church attendance Frequent visits to primary care clinics Unusual stress Family supports

Unusual stress

The nurse is assessing a 74-year-old woman who has come to the clinic. During the interview, the woman complains of not feeling rested in the morning when she awakens. BAsed on the nurse's knowledge about sleep and the older adult, which area would the nurse investigate further? Spiritual beliefs Dietary intake in the evenings Use of alcohol History of seizures

Use of alcohol

The nurse is caring for an older adult client and is reviewing the client's medications. Which finding woudl lead the nurse to suspect polypharmacy? Select all that apply. Use of herbal remedies Use of medications that interact with each other Use of drugs to treat adverse drug reactions Evidence of changes in medications Use of duplicate medications

Use of medications that interact with each other Use of duplicate medications Use of drugs to treat adverse drug reactions Use of herbal remedies

A client has contacted the care provider because of concerns for the client's 55-year-old spouse, who suddenly became very forgetful in recent days. Most recently, the spouse became lost while driving to the spouse's home of 30 years and temporarily forgot the client's adult child's name. The client also had a temporary slurring of speech lasting about a minute. Diagnostic testing has ruled out delirium and the spouse had been previously healthy. Which would the nurse most likely suspect? -Frontotemporal neurocognitive disorder -Alzheimer's disease -Vascular neurocognitive disorder -Neurocognitive disorder with Lewy Bodies

Vascular neurocognitive disorder

Which type of hallucination is most commonly seen in clients diagnosed with delirium? Autonomic Visual Gustatory Auditory

Visual

A client with a heart condition comes to the psychiatric clinic for treatment of depression. The client was recently started on an antidepressant with anticholinergic properties and now reports having a loss of appetite since starting this medication. Which common side effect of the newly prescribed medication would the nurse explain as possibly contributing to the client's loss of appetite? Xerostomia Polyuria Polyphagia Dysphagia

Xerostomia

The client is brought to the clinic with dementia and is unable to recognize ordinary objects, such as a pen or notebook. The family is upset and concerned. The nurse notes that this is a symptom of: agnosia. amnesia. aphasia. apraxia.

agnosia.

The nurse is caring for a client diagnosed with dementia. Based on the nurse's understanding of dementia and the existence of other disorders, the nurse would be alert for signs and symptoms of which disorder? anxiety delusions hopelessness bulimia

anxiety

The nurse documents that a client diagnosed with dementia of the Alzheimer's type is exhibiting agnosia when the client is observed being unable to ... -open juice and insert a straw into the container. -find words to describe the client's daughter's appearance. -button a blouse. -identify a picture of a car.

identify a picture of a car.

One way in which the expression of depressive symptoms in older adults may differ from the presentation in young adults is ... -older adults tend to hold all their feelings in, whereas younger adults do not. -older adults remain close to their families and thus become depressed over daily family issues, whereas younger adults often leave their families of origin. -older adults may somatize, or discuss their depressive symptoms in terms of physical symptoms or aches/pains. -older adults may appear less suicidal than a younger adult who is depressed.

older adults may somatize, or discuss their depressive symptoms in terms of physical symptoms or aches/pains.