Custom: Cognition

A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III? a. Instruct the client to look up and down without moving his head b. Observe the client's ability to smile and frown c. Have the client stand with eyes his closed and touch his nose d. Ask the client to shrug his shoulders against passive resistance

A

A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of pneumonia. During the night shift, the client is found climbing into the bed of another client who becomes upset and frightened. Which of the following actions should the nurse take? a. Assist the client to the correct room b. Place the cleint in restraints. c. Reorient the client to time and place. d. Move the client to a toom at the end of the hall.

A Assisting the client to the coorect room protects both cleints. It helps reorient the client who is unable to find her own room, and it protects the other client from an invasion of her personal space Restrraining a client in situations other than for the client's physical safety is unethical and illegal. This action by the nurse is not appropriate.

A nurse is performing a mental sttus examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (Select all that apply.） a. Grooming b. Long-term memory c. Support systems d. Affect e. Presence of pain

A,B,D MSE consists of apperance, behavior, speech, mood, disorders of the form of thought, perceputal disturbances, cognition, and ideas of harming self or others.

A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE) the nurse should include which of the folowing data? (Select all that apply.) a. Ability to perform calculations b. Level of consciousness c. Recall ability d. Long-term memory e. Level of orientation

A,C,D,E

A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium? a. A client wants to know the current time where there is a clock on the wall. b. A client attempts to climb out of bed and repeately states she must get home. c. A client requests extra blankets when the thermostat in the room indicates 25.6 C d. A client refuses to get out of bed and has no otivation to attend to daily hygiene

B Delirium is characterized by alternations in memory, agitation, restlessness, illusions, or hallucinations. A client who becomes actely confused and agitated may be showing manifestations of delirium

A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the folloing persons should sign the informed consent? a. The client's partner b. The client c. The client's daughter, who is the primary caregiver d. The client's son, who has a durable poer of attorney

B Legal decisions regarding hralth care must be made by a competent person or the person holding the durable power of attorney If the client appears competent, and understands the procedure, the client can sign for informed consent. The nurse should verify that the client gives consent voluntarily, the signature on the consent is the client's and the client appears competent. If the client were disoriented and not competent, the person who has durable poewer of attorney should sign informed consent

A nurse is assessing a client who has ataxia. Whihc of the following actions should the nurse take to evaluate the client's abiltiy to safely ambulate? a. Observe for the presence of Kernig's sign b. Perform a Romberg's test c. Check the function of cranial nerve V d. Inspect for the presence of clubbing

B The nurse should perform a Romberg's test to check the client's abiity to maintain an upright position without swaying when standing with feet close together, with eyes open adn with eyes closed. The nurse must stand close enough to prevent the client from falling

A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which fo the following interventions is the nurse's priority? a. Recommend that the partner place the client in a long-term care facility b. Suggest that the partner see a counselor to help him cope with his exhaustion. c. Ask the parnter to talk about his difficulties in caring for the client d. Tell the partner to call a family meeting to get help

C

A nurse is caring for a client who has dementia due to Alzheimer's disease and was admitted to a long-term care facility following the death of her partner of 40 years. The client states, "I want to go home; my husband is waiting fro me to cook dinner." Which of the following responses by the nurse is appropriate? a. "This is where you live now." b. "This is a safer place for you to live." c. "Tell me what you like to cook for dinner." d. "Your family said there is no one to care for you at home."

C

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data? a. Blood pressure b. Cyanosis c. Nausea d. Petechiae

C

A nurse is making a home visit to a client who has Alxheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiverr role strain? a. The partner has placed locks at the top of the doors leading to the outside. b. The partner has hired a house cleaner c. The partner has lost 20 lb in the past 2 months d. The partner redirects the client when the client is frustrated

C

A nurse is teaching the family of an older adult client who has a new diagnosis of dementia. Which of the following statements should the nurse include in the teaching? a. "Dementia is characterized by a sudden onset of confusion." b. "An altered level of consciousness is associated with dementia." c. "The signs of dementia are progerssive and irreversible." d. "Dementia can be triggered by a high fever or dehydration."

C

The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client finches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factoes should the nurse identify as a likely explanation for the client's behavior? a. He is hard of hearing b. Pain c. Confusion d. Language barrier

C

A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan of care? a. Provide a cognitively stimulating environment b. Rotate staff to prevent caregiver role strain c. Limit the client's choices for daily activities. d. Use confrontation to manage negative behavior

C Limiting the client's choice is appropriate for a client who has dementia as the intervention decreases the client's lvel of anxiety The nurse should use distraction to manage negative behavior and should avoid the use of confrontation which may cause escalation of aggresive behaviors

A nurse is a long-term care facility is caring for a client who has late stage Alzheimer's disease. Which of the following actions should the nurse include int he plan of care? a. Post a written schedule of daily activities b. Use an overhead loudspeaker to announce events c. Provide a consistent daily routine d. Allow the client to choose free-time activities

C Picture symbols, rather than written schedules, are appropriate for the care of a client who has Alzheimer's disease. A consistent daily routine is appropriate for the care of a cleint who has Alzheimer's disease. Providing the client with choices can increases client anxiety and is therefore not appropriate for the care of a client who has Alzheimer's disease

A nurse on a long-term care unit is creating a plan of care for a client who has Azheimer's disease. Which of the following interventions should the nurse include in the plan? a. Rotate assignment of daily caregivers. b. Povide an activity schedule that changes from day to day c. Limit time for the client to perform activities d. Talk the cleint through tasks one step at a time

D

A nurse is caring for a client who is cognitively impaired. Which of the following rooms will provide a therapeutic environment for this client? a. A room adjacent to the nursing station b. A room without a window c. A room with dim lighting d. A room containing personal belongings

D Clients who have impaired cognition need a low-stimulation environment. A room adjacent to the nursing station might provide too much stimulation for this client. A room adjacent to the nursing station might porvide too muh stimulation for this client. Clients who imapried cognition are oftern disoriented and cannot distinguish between night and day. A room without a window may contribute to the disorientation. A room that contains several of the client's personal belongings assists in maintainging personal identity and provides a therapeutic environment.

A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect? a. Decreased auditory and visual acuity b. Decreased display of emotions c. Personality traits that are opposite of original traits d. Forgetfulness gradually progressing to disorientation

D The nurse should tell the family to expect the client to be unable to control emoitions adn behavior, and be more likely to exhibit emoitional outbursts.