Dementia and Delirium Exam
The critical care nurse is giving end-of-shift report on a client she is caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? Comatose Somnolence Stupor Normal
Correct response: Comatose Explanation: The GSC is used to measure the LOC. The scale consists of three parts: eye opening response, best verbal response, and best motor response. A normal response is 15. A score of 7 or less is considered comatose. Therefore, a score of 6 indicates the client is in a state of coma and not in any other state such as stupor or somnolence. The evaluations are recorded on a graphic sheet where connecting lines show an increase or decrease in the LOC.
Which of the following is an age-related change in the nervous system? Increased cerebral blood flow More efficient temperature regulation Increased myelin Loss of neurons in the brain
Correct response: Loss of neurons in the brain Explanation: Structural changes include loss of neurons in the brain, reduced cerebral blood flow, less efficient temperature regulation, and decreased myelin, resulting in decreased nerve conduction in some nerves.
To help assess a client's cerebral function, a nurse should ask: "Have you had any problems with coordination?" "Have you noticed a change in your muscle strength?" "Have you had any problems with your eyes?" "Have you noticed a change in your memory?"
Correct response: "Have you noticed a change in your memory?" Explanation: To assess cerebral function, the nurse should ask about the client's level of consciousness, orientation, memory, and other aspects of mental status. Questions about muscle strength help evaluate the client's motor system. Questions about coordination help her assess cerebellar function. Questions about eyesight help the nurse evaluate the cranial nerves associated with vision.
A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in motor ability thought content intellectual function emotional status
Correct response: thought content. Explanation: Hallucinations are disturbances of thought content. They are not disturbances in motor ability, intellectual function, or emotional status.
A client with moderate Alzheimer's disease has been eating poorly, losing weight, and playing with food at meals. The nurse best intervenes by Cutting the client's food into small pieces Converting liquid foods to a gelatin texture Serving hot foods at a warm temperature Placing one food at a time in front of the client during meals
Correct response: Placing one food at a time in front of the client during meals Explanation: Tasks should be simplified for the client with Alzheimer's disease. All options are steps the nurse can take to promote eating for the client with Alzheimer's disease. Offering one food at a time, however, helps to prevent the client from playing with food.
Which neurotransmitter is implicated in depression? Epinephrine Acetylcholine Atropine Serotonin
Correct response: Serotonin Explanation: Serotonin is implicated in the development of depression. Atropine, acetylcholine, and epinephrine are not implicated in the development of depression.
A family of a patient with Alzheimer's disease asks the nurse what causes this condition? Which response by the nurse would be most appropriate? "The numerous drugs that he was taking contributed to his current confusion." "A specific gene is involved in the development of this disorder." "Evidence shows that there are changes in nerve cells and brain chemicals." "This condition is most likely due to a stroke that the patient didn't realize he had."
Correct response: "Evidence shows that there are changes in nerve cells and brain chemicals." Explanation: Specific neuropathologic and biochemical changes are found in patients with Alzheimer's disease. These include neurofibrillary tanges and neuritic plaques as well as altered neurotransmitter function, specifically acetylcholine. Vascular dementia is associated with a subclinical stroke. Although genetics is being studied as an underlying mechanism for Alzheimer's disease, no specific gene or gentic marker has been identified. Delirium is often the result of the interaction or use of multiple drugs.
The most common affective or mood disorder of old age is depression schizophrenia anxiety disorder phobias.
Correct response: depression. Explanation: Depression is the most common affective or mood disorder of old age. Anxiety disorders, schizophrenia, and phobias are not a common affective or mood disorder of old age.
A nurse is assessing an older adult for depression using the Geriatric Depression Scale. Which question would the nurse ask first? "Are you basically satisfied with your life?" "Do you often get bored?" "Are you in good spirits most of the time?" "Do you feel your life is empty?"
Correct response: "Are you basically satisfied with your life?" Explanation: When using the Geriatric Depression Scale, the nurse would first question the patient about being satisfied with life. Then the nurse would continue the assessment, asking if the patient feels his or her life is empty, if the patient often gets bored, and if the patient is in good spirits most of the time.
The nurse is caring for an elderly client who is being treated for community-acquired pneumonia. Since the time of admission, the client has been disoriented and agitated to varying degrees. Appropriate referrals were made and the client was subsequently diagnosed with dementia. What nursing diagnosis should the nurse prioritize when planning this client's care? Risk for infection related to dementia Hopelessness related to dementia Social isolation related to dementia Acute confusion related to dementi
Correct response: Acute confusion related to dementia Explanation: Acute confusion is a priority problem in clients with dementia, and it is an immediate threat to their health and safety. Hopelessness and social isolation are plausible problems, but the client's cognition is a priority. The client's risk for infection is not directly influenced by dementia.
A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates: dysfunction in the cerebrum dysfunction in the spinal column dysfunction in the brain stem risk for increased intracranial pressure
Correct response: dysfunction in the brain stem. Explanation: Decerebrate posturing indicates damage of the upper brain stem. Decorticate posturing indicates cerebral dysfunction. Increased intracranial pressure is a cause of decortication and decerebration. Alterations in sensation or paralysis indicate dysfunction in the spinal column.
A client reports to the nurse that her elderly mother has become increasingly angry and responds inappropriately to conversations within the past few months. She notes that her mother does not respond when the mother's back is turned. The best intervention of the nurse is to Inform the client to ignore the behavior and the mother will stop. Tell the client it appears the mother has a hearing loss. Ask if the mother could come in for a hearing evaluation. Teach the client techniques for coping with the mother's anger.
Correct response: Ask if the mother could come in for a hearing evaluation. Explanation: The client's mother may be experiencing a hearing loss, and the mother should be evaluated for the symptoms the client has described. The other options do not facilitate assessment and, thus, treatment.
Which condition is characterized by a decline in intellectual functioning? Dementia Depression Delirium Delusion
Correct response: Dementia Explanation: Dementia is an acquired syndrome in which progressive deterioration in global intellectual abilities is of such severity that it interferes with the person's customary occupational and social performance. Depression is a mood disorder that disrupts quality of life. Delirium is often called acute confusional state. Delusion is a symptom of psychoses.
A nurse is preparing a client for a computed tomography (CT) scan that requires infusion of radiopaque dye. Which question is the most important for the nurse to ask? "When did you last take any medication?" "When did you last have something to eat or drink?" "How much do you weigh?" "Are you allergic to seafood or iodine?"
Correct response: "Are you allergic to seafood or iodine?" Explanation: Seafood and the radiopaque dye used in CT contain iodine. To prevent an allergic reaction to the radiopaque dye, the nurse should ask the client about allergies to seafood or iodine before the CT scan. Because fasting is unnecessary before a CT scan, the nurse doesn't need to obtain information about the client's last food and fluid intake. The client's last dose of medication and current weight also are irrelevant.
Family members report to the nurse that their elderly grandmother has had a sudden onset of confusion and that they are having difficulty providing care for her. The nurse Recommends placement of the grandmother in a nursing home Assesses the grandmother for adventitious lung sounds Administers donepezil (Aricept) every day Informs the family that this is a result of aging
Correct response: Assesses the grandmother for adventitious lung sounds Explanation: Sudden onset of confusion may be the first symptom of an infection, such as pneumonia or urinary tract infection. The nurse needs to fully assess the situation before acting (such as telling the family this is a result of aging). Donepezil is used for Alzheimer's disease, which does not have acute onset. A recommendation for placement in a nursing home is premature without a full assessment at this time.
A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution? Analgesics Whirlpool baths Anti-inflammatory medications Hot or cold packs
Correct response: Hot or cold packs Explanation: Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used. The older client may be burned or suffer frostbite before being aware of any discomfort. Any medication is used with caution in the elderly, but not because of the decreased sense of heat or cold. Whirlpool baths are generally not a routine treatment prescribed for the elderly.
A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis? Risk for impaired skin integrity Decreased intracranial adaptive capacity Risk for aspiration Risk for falls
Correct response: Risk for aspiration Explanation: CN X, the vagus nerve, involves the gag reflex, laryngeal hoarseness, swallowing ability, and symmetrical rise of the uvula and soft palate. An impaired gag reflex indicates a danger for aspiration and subsequent pneumonia. An impaired vagus nerve will not affect balance, skin integrity, or intracranial adaptive capacity.
Which structural and motor change is related to aging and may be assessed in geriatric clients during an examination of neurological function? Increased pupillary responses Increased autonomic nervous system responses Enhanced reaction and movement times Decreased or absent deep tendon reflexes
Correct response: Decreased or absent deep tendon reflexes Explanation: Structural and motor changes related to aging that may be assessed in geriatric clients include decreased or absent deep tendon reflexes. Pupillary responses are reduced or may not appear at all in the presence of cataracts. There is an overall slowing of autonomic nervous system responses with aging. Strength and agility are diminished and reaction and movement times are decreased
A nurse is providing care to a patient with delirium. Which interventions would be most appropriate to implement? Select all that apply. Supervising nutritional intake Providing a calm, quiet environment Keeping the patient awake as much as possible Using familiar cues about the environment Administering psychoactive drugs
Correct response: Providing a calm, quiet environment Supervising nutritional intake Using familiar cues about the environment Explanation: Appropriate interventions when caring for a patient with delirium include maintaining a calm, quiet environment, supervising and monitoring nutritional and fluid intake, and using familiar environmental cues. Psychoactive drugs should be minimized to reduce the possibility of delirium. Keeping the patient awake as much as possible would lead to sleep deprivation, which would increase the patient's risk for delirium.
A 72-year-old man has been brought to his primary care provider by his daughter, who claims that he has been experiencing uncharacteristic lapses in memory. What principle should underlie the nurse's assessment and management of this client? Thorough assessment is necessary because changes in cognition are always considered to be pathologic. Lapses in memory in older adults are considered benign unless they have negative consequences. Gradual increases in confusion accompany the aging process. Loss of short-term memory is normal in older adults, but loss of long-term memory is pathologic.
Correct response: Thorough assessment is necessary because changes in cognition are always considered to be pathologic. Explanation: Although mental processing time decreases with age, memory, language, and judgment capacities remain intact. Change in mental status should never be assumed to be a normal part of aging.
A patient with Alzheimer's disease is prescribed donepezil (Aricept). When teaching the patient and family about this drug, which of the following would the nurse include? "This drug will help to stop the disease from getting worse." "The drug helps to control the symptoms of the disease." "He'll need to take this drug for the rest of his life." "Once it becomes effective, you can stop the drug."
Correct response: "The drug helps to control the symptoms of the disease." Explanation: Donepezil is a cholinesterase inhibitor used to control symptoms of Alzheimer's disease. It does not cure or slow progression. Typically cognitive ability improves within 6 to 12 months of therapy, but if stopped, cognitive progression occurs. It is recommended that treatment continue at least through the moderate stage of the illness. However, it usually is not prescribed as life-long therapy.
A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-related changes that may influence the assessment results. Of what phenomenon should the nurse be aware? Hypersensitivity to painful stimuli Increased cerebral metabolism Reduction in cerebral blood flow Hyperactive deep tendon reflexes
Correct response: Reduction in cerebral blood flow Explanation: Reduction in cerebral blood flow (CBF) is a change that occurs in the normal aging process. Deep tendon reflexes can be decreased or, in some cases, absent. Cerebral metabolism decreases as the client advances in age. Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used.
A client reports to the nurse that her grandmother with Alzheimer's disease recently moved in with her and her two school-aged children. The client states the grandmother becomes agitated and starts yelling and crying frequently. The woman asks, "What can I do?" The nurse first responds: "You need to remain calm during the outbursts." "Start rubbing her shoulders and her back." "Play quiet music that your grandmother may like." "What precipitates the outbursts?"
Correct response: "What precipitates the outbursts?" Explanation: A client with Alzheimer's disease may respond to exciting or confusing events with a catastrophic reaction, such as screaming, crying, or becoming abusive. The nurse needs to assess the situation and what precipitates the catastrophic reactions to best address how to prevent these events. Other nursing interventions include telling the client's granddaughter to remain calm and to distract the grandmother with quiet music, stroking, or both.
When completing a neurologic examination on a client, which question is most essential to evaluate the accuracy of the data? When, if any, was your last narcotic use? Have you experienced any unusual sensations? Do you have any history of forgetfulness? Have you been diagnosed with any mental health issues?
Correct response: When, if any, was your last narcotic use? Explanation: When completing a neurologic exam, it is essential to assess the use of morphine, heroin, narcotic, or central nervous system depressant because these affect the results of a neurologic examination. These types of drugs decrease the level of consciousness. The nurse can observe forgetfulness and mental status. Experiencing unusual sensations is good subjective data to have but is not essential to evaluate the accuracy of objective data.
Nurses and members of other health disciplines at a state's public health division are planning programs for the next 5 years. The group has made the decision to focus on diseases that are experiencing the sharpest increases in their contributions to the overall death rate in the state. This team should plan health promotion and disease prevention activities to address what health problem? Stroke Alzheimer disease Respiratory infections Cancer
Correct response: Alzheimer disease Explanation: In the past 60 years, overall deaths, and specifically, deaths from heart disease, have declined. Recently, deaths from cancer and cerebrovascular disease have declined. However, deaths from Alzheimer disease (AD) among those 65 years and older have risen and are projected to be approximately 1.6 million annually by 2050.
An older adult develops sudden onset of confusion and is hospitalized. The family expresses concern that their loved one is developing Alzheimer disease. What response by the nurse is most appropriate? "Several possible underlying factors could be causing the confusion. Alzheimer's usually does not present with sudden confusion." "Once the underlying cause of the confusion is found and treated, your loved one will be better than ever." "What concerns you most about Alzheimer disease?" "Alzheimer disease can be a great burden on the family. What community resources do you know about?"
Correct response: "Several possible underlying factors could be causing the confusion. Alzheimer's usually does not present with sudden confusion." Explanation: Delirium is associated with a sudden onset of confusion, not Alzheimer disease. The family needs to be told the correct information, which is that several underlying conditions could be causing the confusion. Once the underlying cause(s) is found and treated, the confusion should subside; however, some clients may not recover from the underlying cause, so telling the family the client will be better than ever is not appropriate. Asking the family about their concerns about Alzheimer disease and what they know about community support related to it is not appropriate because the client is exhibiting symptoms related to delirium.
A nurse is caring for a client with dementia. A family member of the client asks what the most common cause of dementia is. Which response by the nurse is most appropriate? "Drug interactions are the most common cause of dementia in the elderly." "The most common cause of dementia in the elderly is Alzheimer's disease." "Depression may manifest as dementia in elderly clients." "Dementia is a terrible disease of the elderly."
Correct response: "The most common cause of dementia in the elderly is Alzheimer's disease." Explanation: The nurse should inform the family member that Alzheimer's disease is the most common cause of dementia in elderly clients. Dementia is a clinical manifestation, not a disease process. Although drug interactions and overmedication are causes of dementia, these causes aren't as common as Alzheimer's disease. Depression is common in elderly clients, but it doesn't cause dementia.
The nurse is assessing the client's mental status . Which question will the nurse include in the assessment? "Who is the president of the United States?" "Can you write your name on this piece of paper?" "Are you having hallucinations now?" "Can you count backward from 100?"
Correct response: "Who is the president of the United States?" Explanation: Assessing orientation to time, place, and person assists in evaluating mental status. Does the client know what day it is, what year it is, and the name of the president of the United States? Is the client aware of where he or she is? Is the client aware of who the examiner is and why he or she is in the room? "Can you write your name on this piece of paper?" will assess language ability. "Can you count backward from 100?" assesses the client's intellectual function. "Are you having hallucinations?" assesses the client's thought content.
The nurse is caring for a male client who is scheduled for a neurologic examination that uses a radiopaque dye. Before the test, the nurse assesses the allergy history of the client and find the client is allergic to seafood. What does the nurse relate the allergy to seafood as? An allergy to iodine An allergy to antihistamines An allergy to radiation exposure An allergy to morphine
Correct response: An allergy to iodine Explanation: Because some contrast media contain iodine, the nurse checks the client's history for previous allergic reactions to radiographic dyes, iodine, or seafood. Seafood allergies indicate an allergy to iodine. Therefore, the nurse will have to manage the allergic reaction of the client by administering antihistamines or any other medications suggested by the physician. Alternatively, the physician may suggest another neurologic examination test that does not require the use of a radiopaque dye. Allergy to seafood does not indicate an allergy to morphine or radiation exposure.
A health care team is involved in caring for a client with advanced Alzheimer's disease. During a team conference, a newly hired nurse indicates that she has never cared for a client with advanced Alzheimer's disease. Which key point about the disease should the charge nurse include when teaching this nurse? The nursing staff should rely on the family to assist with care because family members know the client best. As long as the client receives the ordered medication, special care measures aren't necessary. Alzheimer's disease affects memory so the client doesn't need an explanation before procedures are performed. Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgment.
Correct response: Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgment. Explanation: The charge nurse should inform the new nurse that clients with Alzheimer's disease are at high risk for injury because they have impaired memory and poor judgment. Maintaining a safe environment takes top priority. Families are an important part of the client care team; however, they shouldn't be relied upon to deliver care. Family members may take turns sitting with the hospitalized client to help maintain client safety. All procedures should be explained in simple terms that the client can understand. Medications should be administered as ordered; however, they don't typically improve symptoms. Instead, they slow disease progression.
A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes? Increased acetylcholine level Increased norepinephrine level Decreased acetylcholine level Decreased norepinephrine level
Correct response: Decreased acetylcholine level Explanation: A decreased acetylcholine level has been implicated as a cause of cognitive changes in healthy elderly clients and in the severity of dementia. Choline acetyltransferase, an enzyme necessary for acetylcholine synthesis, has been found to be deficient in clients with dementia. Norepinephrine is associated with aggression, sleep-wake patterns, and the regulation of physical responses to emotional stimuli, such as the increased heart and respiratory rates caused by panic.
An 84-year-old client has returned from the post-anesthetic care unit (PACU) following hip arthroplasty. The client is oriented to name only. The client's family is very upset because, before having surgery, the client had no cognitive deficits. The client is subsequently diagnosed with postoperative delirium. What should the nurse explain to the client's family? Delirium of this type is treatable and her cognition will return to previous levels. Delirium involves a progressive decline in memory loss and overall cognitive function. This problem is self-limiting and there is nothing to worry about. This problem can be resolved by administering antidotes to the anesthetic that was used in surgery.
Correct response: Delirium of this type is treatable and her cognition will return to previous levels. Explanation: Surgery is a common cause of delirium in older adults. Delirium differs from other types of dementia in that delirium begins with confusion and progresses to disorientation. It has symptoms that are reversible with treatment, and, with treatment, is short term in nature. It is patronizing and inaccurate to reassure the family that there is "nothing to worry about." The problem is not treated by the administration of antidotes to anesthetic.
A client with Alzheimer disease becomes agitated while the nurse is attempting to take vital signs. What action by the nurse is most appropriate? Document the inability to assess vital signs due to client's agitation. Continue taking the vital signs. Place the client in a secluded room until calm. Distract the client with a familiar object or music.
Correct response: Distract the client with a familiar object or music. Explanation: The nurse should try to calm the patient by using distraction with a familiar object or music. Continuing to take the vital signs will cause further agitation and possible harm to the client or nurse. Placing the client in a secluded room may increase agitation and should not be used in this situation. The nurse should document the inability to assess vital signs and the reason why this should be done after the client's basic needs have been met.
Which actions by the nurse will assist in promoting an older adult's adherence to medication therapy? Select all that apply. Encourage the client to keep a list of medications and review it frequently for updates. Educate the client to keep all medications and bottles for future reference. Instruct the client not to take herbal supplements. Encourage the patient to use multiple pharmacies to obtain cheapest prices. Provide a written medication schedule. Use easy-to-open lids.
Correct response: Encourage the client to keep a list of medications and review it frequently for updates. Use easy-to-open lids. Provide a written medication schedule. Explanation: The client should be encouraged to keep an updated list of medications because it may decrease the chance of adverse reactions from physicians prescribing medications that will interact. Older adults may find it difficult to open the safety lids, and the use of easy-to-open lids may increase adherence. A written schedule may help the older adult follow a medication routine, thereby increasing adherence. Any medication that is not being used should be destroyed and the bottles thrown away. The client may still take herbal supplements, but the prescribing physicians must be aware of it. Although cost may cause the older adult not to take a medication, using multiple pharmacies increases the risk of adverse drug reactions. Other options should be explored if medication cost is a cause of nonadherence.
What safety actions does the nurse need to take for a client receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)? Check the client's oxygen saturation level using a pulse oximeter after the client has been placed on the MRI table Ensure that no client care equipment containing metal enters the room where the MRI is located. Securely fasten the client's portable oxygen tank to the bottom of the MRI table after the client has been positioned on the top of the MRI table Note that no special safety actions need to be taken
Correct response: Ensure that no client care equipment containing metal enters the room where the MRI is located. Explanation: For client safety the nurse must make sure no client care equipment that contains metal or metal parts (e.g., portable oxygen tanks) enters the room where the MRI is located. The magnetic field generated by the unit is so strong that any metal-containing items will be strongly attracted and can literally be pulled away with such great force that they can fly like projectiles toward the magnet.
A client has recently brought her elderly mother home to live with her family. The client states that her mother has moderate Alzheimer's disease and asks about appropriate activities for her mother. The nurse tells the client to Turn off lights at night so that the mother differentiates night and day. Encourage the mother to take responsibility for cooking and cleaning the house. Ensure that the mother does not have access to car keys or drive an automobile. Allow the mother to smoke cigarettes outside on the porch without supervision.
Correct response: Ensure that the mother does not have access to car keys or drive an automobile. Explanation: A person with Alzheimer's disease needs to be provided with a safe environment. Driving is prohibited. Cooking and cleaning may be too much stimulation and place the client in danger. Daily activities must be simplified, short, and achievable. Smoking is allowed only with supervision. The person needs adequate lighting, and nightlights are helpful, particularly if the person has increased confusion at night.
A nurse is presenting a safety program to a group of older adults at a continuing care retirement community. The nurse emphasizes measures to reduce the risk of falls based on the understanding that which type of fracture is the most common? Femur Hip Ankle Forearm
Correct response: Hip Explanation: The most common fracture resulting from falls is hip fracture, which is linked to both osteoporosis and the situation that provoked the fall. Many older adults who fall and sustain a hip fracture cannot regrain their prefracture ability.
A client in a nursing home is diagnosed with Alzheimer's disease. He exhibits the following symptoms: difficulty with recent and remote memory, irritability, depression, restlessness, difficulty swallowing, and occasional incontinence. This client is in what stage of Alzheimer's disease? III I II IV
Correct response: II Explanation: Stage II is characterized by the above-listed symptoms as well as communication difficulties, motor disturbances, forgetfulness, and psychosis. This stage lasts 2 to 10 years. Stage I, which lasts 1 to 3 years, is characterized by memory loss, poor judgment and problem-solving, difficulty adapting to new environments and challenges, and agitation or apathy. Stage III is characterized by loss of all mental abilities and the ability to care for self. There is no stage IV.
The plan of care for a patient with advanced Alzheimer's disease includes the nursing diagnosis of risk for injury. The nurse has identified this nursing diagnosis most likely as related to which of the following? Personality changes Communication difficulties Separation from others Impaired memory
Correct response: Impaired memory Explanation: Patients with Alzheimer's disease are at high risk for injury because they have impaired memory and poor judgment. They also exhibit impulsivity, which increases their risk. Maintaining a safe environment takes top priority. Communication difficulties could be the basis for several nursing diagnoses such as impaired verbal communication, powerlessness, and impaired social interaction. Separation from others could lead to social isolation, impaired social interaction, and social isolation. Personality changes may lead to a risk for self- or other directed violence, chronic low self-esteem, and risk for suicide.
The nurse is providing client teaching to a client with early stage Alzheimer disease (AD) and her family. The client has been prescribed donepezil hydrochloride. What should the nurse explain to the client and family about this drug? It limits the physical effects of AD and other dementias. It slows the progression of AD. It cures AD in a small minority of clients. It removes the client's insight that he or she has AD.
Correct response: It slows the progression of AD. Explanation: There is no cure for AD, but several medications have been introduced to slow the progression of the disease, including donepezil hydrochloride (Aricept). These medications do not remove the client's insight or address physical symptoms of AD.
A nurse is working with the family of a patient with Alzheimer's disease to develop an appropriate plan of care. Which of the following would the nurse suggest to foster socialization? Encouraging participation in multiple-stepped activities Promoting frequent lengthy visits from friends Promoting hobbies involving fine motor skills Limiting visitors to one or two at a time
Correct response: Limiting visitors to one or two at a time Explanation: When promoting socialization, visits, letters, and phone calls are encouraged. Visits should be brief and nonstressful, limiting visitors to one or two at a time to reduce overstimulation. The patient also is encouraged to participate in simple activities. Activities with multiple steps and hobbies requiring fine motor activity increase the risk of frustration, leading to the patient becoming overwhelmed.
The nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response? Assessing the client's sensitivity to temperature, touch, and pain Using the Romberg test Observing the reaction of pupils to light Observing the client's response to painful stimulus
Correct response: Observing the client's response to painful stimulus Explanation: The nurse evaluates motor response in a comatose or unconscious client by administering a painful stimulus. This action helps determine if the client makes an appropriate response by reaching toward or withdrawing from the stimulus. The Romberg test is used to assess equilibrium in a noncomatose client. Pupils are examined for their reaction to light to assess sensitivity in the third cranial (oculomotor) nerve. Sensitivity to temperature, touch, and pain is a test to assess the sensory function of the client and not motor response.
An older adult was diagnosed with Alzheimer disease 2 years ago and the disease has progressed at an increasing pace in recent months. The client has lost 7.5 kg (16 pounds) over the past 3 months, leading to a nursing diagnosis of Imbalanced Nutrition: Less than Body Requirements. What intervention should the nurse include in this client's plan of care? Offer the client only one food item at a time to promote focused eating. Arrange for insertion of a gastrostomy tube and initiate enteral feeding. Offer the client rewards for finishing all the food on her tray. Offer the client bland, low-salt foods to limit offensiveness.
Correct response: Offer the client only one food item at a time to promote focused eating. Explanation: To avoid any "playing" with food, one dish should be offered at a time. Foods should be familiar and appealing, not bland. Tube feeding is not likely necessary at this time and a reward system is unlikely to be beneficial.
A nurse conducts the Romberg test by asking the client to stand with the feet close together and the eyes closed. As a result of this posture, the client suddenly sways to one side and is about to fall when the nurse intervenes and prevents the client from being injured. In which way should the nurse interpret the client's result? Negative Romberg test, indicating a problem with vision Positive Romberg test, indicating a problem with level of consciousness Negative Romberg test, indicating a problem with body mass Positive Romberg test, indicating a problem with equilibrium
Correct response: Positive Romberg test, indicating a problem with equilibrium Explanation: If the client sways and starts to fall during the Romberg test, it indicates a positive result. This means the client has a problem with equilibrium. The examiner or the nurse stands fairly close to the client during the test to prevent the client from falling. The Romberg test is used to assess the client's motor function, including muscle movement, size, tone, strength, and coordination. However, the Romberg test is not used to assess the client's level of consciousness, body mass, or vision.
An elderly client recovering from a hip repair becomes disoriented and tries to get out of bed frequently. The client states, "I forget I am in the hospital." The best nursing intervention is to Administer an oral dose of prescribed alprazolam (Xanax). Raise the upper and lower side rails of the bed. Place the client in a Posey chest restraint with ties attached to the bed frame. Post a sign stating "You are in the hospital" at the client's eye level.
Correct response: Post a sign stating "You are in the hospital" at the client's eye level. Explanation: Client confusion increases the risk of falls. Environmental cues include a sign stating, "You are in the hospital." Measures that are nonrestraining are used first. Raising the lower side rails is considered a restraint. This increases a confused client's risk for falling. Placing a client in a Posey chest restraint is a last resort. Administering an anti-anxiety medication can increase confusion in a client who is already confused.
A geriatric nurse practitioner is assessing older adults. The nurse practitioner knows that older adults sometimes have difficulty following directions during a neurologic examination or diagnostic procedure. What strategies can the nurse practitioner use to examine older clients? Provide brief instructions, one step at a time Offer incentives such as sweets Spread the examination over 2 or 3 days Suggest a nurse or an examiner who is of their age
Correct response: Provide brief instructions, one step at a time Explanation: Older adults who have difficulty following directions during a neurologic examination or diagnostic procedure need brief instructions given one step at a time during the examination or procedure. In addition, diseases that are more common in older adults, such as dementia, often make it difficult to perform a neurologic assessment. The nurse should not offer incentives to them. In addition, spreading the examination over a couple of days or suggesting an examiner of their age may not help in examining older adults.
What is a nurse's role in providing home care for a client with Alzheimer disease? Provide assistance with administering IV fluids Support client with household errands Provide emotional and physical support Contact the Motor Vehicle Department to have driver's license revoked.
Correct response: Provide emotional and physical support. Explanation: Home health care nurses provide emotional support and intervene if family caregivers become overburdened. The nurse also instructs the family about physical care, the disease process, and treatment. Administering IV fluids or supporting clients with household errands is not a relevant role for a home nurse. The nurse should provide education about safety, saying that the client with Alzheimer disease should not drive, but contacting the licensing department is not the nurse's responsibility.
A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize what action? Initiating an IV line for administration of contrast Instructing the patient to void prior to the MRI Removing all metal-containing objects Withholding stimulants 24 to 48 hours prior to exam
Correct response: Removing all metal-containing objects Explanation: Client preparation for an MRI consists of removing all metal-containing objects prior to the examination. Withholding stimulants would not affect an MRI; this relates to an electroencephalography (EEG). Instructing the client to void is client preparation for a lumbar puncture. Initiating an IV line for administration of contrast would be done if the client was having a CT scan with contrast.
The nurse is attempting to take vital signs of an older adult hospitalized following knee surgery. The client continuously yells, "It's 1999 and you are going to hurt me!" What action should the nurse do first? Reorient the patient Take the vital signs Notify the physician Assess for infection.
Correct response: Reorient the patient. Explanation: The first action that should be taken by the nurse is to reorient the patient. Hospitalized older adults are at risk for disorientation and confusion. Although the nurse will still need to take the vital signs and assess for infection, reorienting the client remains the first action. If the client can be reoriented, then the nurse may be able to complete the other actions without difficulty or potentially harming the client. The nurse may need to notify the physician if the client is unable to be oriented or if the assessment is abnormal.
After a sudden decline in cognition, a 77-year-old man who has been diagnosed with vascular dementia is receiving care in his home. To reduce this man's risk of future infarcts, what action should the nurse most strongly encourage? Rigorous control of the client's blood pressure and serum lipid levels Use of mobility aids to promote independence Adequate nutrition and fluid intake Activity limitation and falls reduction efforts
Correct response: Rigorous control of the client's blood pressure and serum lipid levels Explanation: Because vascular dementia is associated with hypertension and cardiovascular disease, risk factors (e.g., hypercholesterolemia, history of smoking, diabetes) are similar. Prevention and management are also similar. Therefore, measures to decrease blood pressure and lower cholesterol levels may prevent future infarcts. Activity limitation is unnecessary and infarcts are not prevented by nutrition or the use of mobility aids.
A client with Alzheimer's disease is admitted for hip surgery after falling and fracturing the right hip. The client's spouse tells the nurse about feeling guilty for letting the accident happen and reports not sleeping well lately because the spouse has been getting up at night and doing odd things. Which nursing diagnosis is most appropriate for the client's spouse? Defensive coping related to diagnosis of Alzheimer's disease Risk for caregiver role strain related to increased client care needs Decisional conflict related to lack of relevant treatment information Relocation stress syndrome related to hospitalization
Correct response: Risk for caregiver role strain related to increased client care needs Explanation: The client's spouse is at risk for caregiver role strain because the client has started to exhibit care needs beyond the spouse's capacity to provide. A diagnosis of Relocation stress syndrome may be appropriate for a client with inadequate preparation for hospital admission, transfer, or discharge; however, this client is confused and may be unable to grasp the meaning of such preparation. The spouse, on the other hand, is more likely to be relieved, at least physically, and able to rest because of the client's admission. Defensive coping and Decisional conflict aren't pertinent nursing diagnoses in this situation because the client's spouse is aware of and has accepted the client's disease.
The nurse is caring for a client with late-stage Alzheimer disease. The client's wife states that the client has now become completely dependent and that she feels guilty if she takes any time for herself. What outcomes would be appropriate for the nurse to develop in order to assist the client's wife? The caregiver distinguishes essential obligations from those that can be controlled or limited. The caregiver prioritizes her own health over that of the client. The caregiver leaves the client at home alone for short periods of time to encourage independence. The caregiver learns to explain to the client why she needs time for herself.
Correct response: The caregiver distinguishes essential obligations from those that can be controlled or limited. Explanation: For prolonged periods, it is not uncommon for caregivers to neglect their own emotional and health needs. The caregiver must learn to distinguish obligations that she must fulfill and limit those that are not completely necessary. The caregiver can tell the client when she leaves, but she should not expect that the client will remember or will not become angry with her for leaving. The caregiver should not leave the client home alone for any length of time because it may compromise the client's safety. Being thoughtful and selective with her time and energy is not synonymous with prioritizing her own health over than of the client; it is more indicative of balance and sustainability.
The nurse is preparing to assess a client with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply. Understanding of the tests used to diagnose neurologic disorders Knowledge of the anatomy of the nervous system The ability to interpret the results of diagnostic tests The ability to select basic medications for the neurologic dysfunction Knowledge of nursing interventions related to assessment and diagnostic testing
Correct response: Understanding of the tests used to diagnose neurologic disorders Knowledge of nursing interventions related to assessment and diagnostic testing Knowledge of the anatomy of the nervous system Explanation: Assessment requires knowledge of the anatomy and physiology of the nervous system and an understanding of the array of tests and procedures used to diagnose neurologic disorders. Knowledge about the nursing implications and interventions related to assessment and diagnostic testing is also essential. Selecting medications and interpreting diagnostic tests are beyond the normal scope of the nurse.
A client at an extended-care facilty who has Alzheimer's disease is awake throughout the night. The nurse intervenes with activities that will promote sleep at night, which include Walking the client in the facility yard during the day Providing a glass of warm milk for breakfast Having the client sit at the nurse's station during night-time hours Allowing the client to take a 2-hour nap in the afternoon
Correct response: Walking the client in the facility yard during the day Explanation: Regular exercise during the day will enhance sleep at night for clients with Alzheimer's disease. Another activity that helps for interrupted sleep, inability to fall asleep, or both is drinking warm milk at night. The nurse should discourage excessive sleep during the day. Sitting at the nurse's station may be too stimulating at night-time hours.
A nurse is reviewing the medications of a client who lives alone and reports having difficulty remembering when to take them. To aid in medication compliance, which of the following measures would the nurse employ? Select all answers that apply. Encourage the client to use containers with safety lids. Suggest that the client use a multiple-dose medication dispenser. Write down the medication schedule for the client. Remind the client to keep empty medication containers to demonstrate use. Recommend to the client to use one pharmacy for all prescriptions.
Correct response: Write down the medication schedule for the client. Suggest that the client use a multiple-dose medication dispenser. Recommend to the client to use one pharmacy for all prescriptions. Explanation: Strategies to help clients improve medication compliance include providing a written copy of the medication schedule; encouraging the use of a multiple-day, multiple-schedule medication dispenser; and recommending the use of one pharmacy for prescriptions. If no children are in the household, then the nurse may encourage the use of standard medication containers without safety lids for ease of opening. Keeping empty medication containers will only add to confusion, so the nurse should encourage the client to dispose of them when they are finished.
A nurse is caring for an elderly adult client admitted to the hospital from a nursing home because of a change in behavior. The client has a diagnosis of Alzheimer's disease and has started to experience episodes of incontinence. The hospital staff is having difficulty with toileting because the client wanders around the unit all day. To assist with elimination, a nurse should: ask the physician to order sedation to allow the client to rest ask the physician to order restraints to prevent wandering incorporate the client's toileting schedule into the pattern of his wandering have the client wear two briefs at a time to ensure absorption of incontinent urine.
Correct response: incorporate the client's toileting schedule into the pattern of his wandering. Explanation: Incorporating the client's toileting schedule into his wandering assists with elimination and increases the chance of continent episodes. Sedation and restraints will decrease the client's mobility but won't decrease the number of incontinent episodes. Wearing two briefs at a time won't ensure urine absorption and won't address the incontinence issue.
A nurse is planning discharge teaching for an older adult client with mild short-term memory loss. The discharge teaching will include how to perform basic wound care for the venous ulcer on the client's lower leg. When planning the necessary health education for this client, the nurse should: keep visual cues to a minimum to enhance the client's focus set long-term goals with the client keep teaching periods short. provide a list of useful websites to supplement learning.
Correct response: keep teaching periods short. Explanation: To assist the elderly client with short-term memory loss, the nurse should keep teaching periods short, provide glare-free lighting, link new information with familiar information, use visual and auditory cues, and set short-term goals with the client. The client may or may not be open to the use of online resources.
The nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response? observing the client's response to painful stimulus using the Romberg test observing the reaction of pupils to light assessing the client's sensitivity to temperature, touch, and pain
Correct response: observing the client's response to painful stimulus Explanation: The nurse evaluates motor response in a comatose or unconscious client by administering a painful stimulus. This action helps determine if the client makes an appropriate response by reaching toward or withdrawing from the stimulus. The Romberg test is used to assess equilibrium in a noncomatose client. Pupils are examined for their reaction to light to assess sensitivity in the third cranial (oculomotor) nerve. Sensitivity to temperature, touch, and pain is a test to assess the sensory function of the client and not motor response.
To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should: give the client privacy during meals help the client fill out his menu fill out the menu for the client stay with the client and encourage him to eat
Correct response: stay with the client and encourage him to eat. Explanation: Staying with the client and encouraging him to feed himself will ensure adequate food intake. A client with Alzheimer's disease can forget how to eat. Allowing privacy during meals, filling out the menu, or helping the client to complete the menu doesn't ensure adequate nutritional intake.
A client with Alzheimer's disease is being treated for malnutrition and dehydration. The nurse decides to place him closer to the nurses' station because of his tendency to: exhibit acquiescent behavior forget to eat not change his position often wander
Correct response: wander. Explanation: A client with Alzheimer's disease is at risk for injury because of his tendency to wander. Placing him closer to the nurses' station makes it easier to monitor him and better ensures his safety if he begins to wander. Placing the client closer to the nurses' station won't help the client remember to eat, change his position often, or modify his behavior.
