Final Exam - Chapter 24
Which would not be considered a primary goal of nursing care for a client with delirium?
Achievement of self-esteem needs
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
A nurse is assessing a client diagnosed with Alzheimer's disease. As part of the assessment, the nurse asks the client to identify common objects. The nurse is assessing for what?
Agnosia
When assessing a client with dementia, the nurse notes that the client is having difficulty identifying common items, such as a ball or book. The nurse interprets this finding as what?
Agnosia
The nurse is caring for a client with dementia. The client's brain images show atrophy of cerebral neurons and enlargement of the third and fourth ventricles. What is the cause of dementia in this client?
Alzheimer's disease
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.
A client was admitted to an inpatient unit with a diagnosis of dementia. A nursing assessment and interview of the client would include what?
Intellectual ability, health history, and self-care ability
The client is a 68-year-old who has been showing signs of Alzheimer's disease, including visual hallucinations and disturbed behaviors. When the client was placed on antipsychotic medications, the client suffered significant adverse reactions. This could indicate that the client does not have Alzheimer's disease, but which condition?
Lewy body dementia
Which is the priority intervention for a client diagnosed with delirium?
Maintenance of safety
While reviewing the medical record of a client with moderate dementia of the Alzheimer type, a nurse notes that the client has been receiving memantine. The nurse identifies this drug as which type?
N-methyl-D-aspartate (NMDA) receptor antagonist
A group of nursing students is reviewing information about delirium and its causes. The students demonstrate a need for additional review when they identify which as a cause of this medical condition?
Oxidative stress
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?
Personality change, wandering, and inability to perform purposeful movements
The client has advanced Alzheimer's disease and becomes confused at mealtimes. The client has agnosia, apraxia, and disturbed executive functioning. Which is the most appropriate nursing intervention?
Provide the client with a tray, opening containers for the client.
A client is in the mild stage of dementia due to Alzheimer's disease. Which intervention would be most appropriate?
Providing emotional support and gentle reminders
A nurse's aide has rung the call light for assistance while providing a client's twice-weekly bath because the client became agitated and aggressive while being undressed. Knowing that the client has a diagnosis of Alzheimer's disease and is prone to agitation, which measure may help in preventing this client's agitation?
Reminding the client multiple times that he or she will be soon having a bath
The nurse is assessing a client who is diagnosed with delirium. Which presenting sign in the client indicates to the nurse that the client may may have a diagnosis of dementia?
Remote memory loss
Which nursing diagnosis would be the priority for the client experiencing acute delirium?
Risk for injury related to confusion and cognitive deficits
To manage voiding issues, such as incontinence, male clients diagnosed with dementia would best be managed by what?
Use of disposable, adult diapers
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 ...
identify a picture of a car.
What is the initial intervention the nurse should implement when helping a client diagnosed with dementia deal with paranoid delusions?
observe the client in order to identify the triggers for the delusions
What is the greatest benefit support groups provide to the caregivers of clients diagnosed with dementia?
provides interaction with those with similar concerns
Which client behavior should the nurse attempt to change when managing a client's tendency to wander and pace at night?
take a nap mid afternoon and before dinner
The nurse should consider the intervention referred to as "going along with" when managing the care of which client?
the older widower who is worried about his wife not being able to visit because of the snow
The client is an 84-year-old suffering from delirium. The client has been in a nursing home for the past 2 years but recently is becoming combative and has become a threat to staff. Which medication would the client most likely receive for these symptoms?
Haloperidol
A nurse is caring for a client diagnosed with delirium who has been brought for treatment by the client's adult child. While taking the client's history, which question would be most appropriate for the nurse to ask the client's adult child?
"Has your parent taken any medications recently?"
The nurse is assessing a client who has received a tentative diagnosis of delirium. The nurse is explaining to the family about the major cause of the client's condition. Which statement by the nurse would be most appropriate?
"The client's diagnosis is primarily based on the rapid onset of the change in consciousness."
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?
"You're in the hospital. You did not drink for several days, but you're getting better now."
The nurse understands that numerous comorbidities can contribute to the development of dementia. Which client may be at risk for dementia?
A 49-year-old client whose human immunodeficiency virus (HIV) has progressed to acquired immunodeficiency syndrome (AIDS)
In clients with Alzheimer's disease, neurotransmission is reduced, neurons are lost, and the hippocampal neurons degenerate. Which neurotransmitter is most involved in cognitive functioning?
Acetylcholine
After teaching a group of nursing students about dementia, the instructor determines a need for additional teaching when the students identify which as a primary goal of nursing care?
Achievement of self-esteem needs
What is the primary sign of delirium?
An altered level of consciousness
Which term is used to describe the inability to execute motor functioning, despite intact motor abilities?
Apraxia
When giving tacrine to an elderly client, the nurse must be aware of what information?
Because the liver is most vulnerable to tacrine, liver function tests must be done periodically.
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?
Delirium related to underlying medical problem
The spouse caregiver of a client with dementia tells the nurse that the client has been agitated lately. The spouse states, "I don't know how to handle this. The client was always such a gentle person!" Which interventions should the nurse suggest?
Distract the client with family photos and discuss the events pictured.
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
A client with Alzheimer's disease is admitted to an acute care facility for treatment of an infection. Assessment reveals that the client is anxious. When developing the client's plan of care, which would be least appropriate for a nurse to include?
Frequently provide reality orientation
A nurse is providing education to the care provider of a cognitively impaired client who is prescribed a cholinesterase inhibitor. Which information about medication side effects should the nurse be sure to include?
Gastrointestinal (GI) symptoms
A client with amnestic disorder is being evaluated for dementia. Which is a diagnostic characteristic of amnestic disorder?
History and physical examination indicative of memory impairment
A nurse is preparing a presentation for a group of staff nurses about neurocognitive disorders. When describing vascular neuorocognitive disorder, the nurse would identify which as posing the greatest risk for this disorder?
Hypertension
Which is a metabolic cause of delirium?
Hypoglycemia
A nurse is caring for a client with delirium. The client sees a thermometer on the nurse's table and shouts, "Don't stab me!" and cowers. Which feature of delirium is this client exhibiting?
Illusion
Delirium can be differentiated from many other cognitive disorders in which way?
It has a rapid onset and is highly treatable if diagnosed quickly.
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 bowel movements.
Which of these is a N-methyl-D-aspartic acid (NMDA) receptor antagonist?
Memantine
A client with a medical diagnosis of dementia of Alzheimer's type has been increasingly agitated in recent days. As a result, the nurse has identified the nursing diagnosis of "risk for injury related to agitation and confusion" and an outcome of "the client will remain free from injury." What intervention should the nurse use in order to facilitate this outcome?
Monitor amount of environmental stimulation and adjust as needed.
A client with dementia becomes extremely agitated shortly after being admitted to the psychiatric unit. The nurse is reluctant to use physical restraints to control the client. What is a likely reason the nurse has this reluctance?
Physical restraints may increase the client's agitation.
A older adult client develops delirium secondary to an infection. Which would be the most likely cause?
Pneumonia
Which is an infection-related cause of delirium?
Pneumonia
A care aide has rung the call light for assistance while providing a client's twice-weekly bath because the client became agitated and aggressive while being undressed. Knowing that the client has a diagnosis of dementia of Alzheimer's type and is prone to agitation, which measure may help in preventing this client's agitation?
Reminding the client multiple times that he or she will be soon having a bath
The client is 79 years old and has been diagnosed with dementia. Continuing assessment reveals that the client's condition is progressing significantly. Which would be the priority when providing care?
Safety
Which can be identified as a hallmark symptom of dementia?
Short-term memory loss
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?
Signs of delirium
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
A client is diagnosed with dementia related to Parkinson's disease. While at a clinic visit, a cholinesterase inhibitor is prescribed for the client. The nurse knows that this type of medication would be prescribed for the client to achieve which goal?
Slow deterioration of memory and function
The nurse is caring for a client with delirium. Which interventions may help manage this client? Select all that apply.
Speak in simple sentences. Provide orienting verbal cues when talking with the client. Allow adequate time for the client to comprehend and respond.
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 confabulating, most likely to cover for memory deficit.
The diagnosis of delirium is supported when the nurse notes which in the client?
The is convinced that the client sees "hundreds" of bugs and is not always oriented to time and place
The nurse is assessing a client with aphasia and notes the client may be exhibiting echolalia during their conversation. What signs does the nurse observe that leads to this conclusion?
The client may echo whatever is heard.
The nurse is interviewing a 50-year-old with a suspected cognitive disorder. The client has a long history of alcoholism. When the nurse asks if the client is employed, the client replies that the client is currently employed as a conductor on a national railway system. The client's spouse takes the nurse aside and informs the nurse that the client hasn't worked for several years and never worked for the railway. The nurse attributes the client's answer to which explanation?
The client may have Korsakoff's syndrome.
The nurse asks a client to pretend the client is brushing the client's teeth. The client is unable to perform the action. Upon examination, the nurse finds that the client possesses intact motor abilities. What can this problem be documented as?
The client may have apraxia.
A 65-year-old has been admitted to the intensive care unit following surgical resection of the bowel. The client has developed a fever. Which additional signs indicate the client has developed delirium?
The client removes the client's surgical bandage and begins picking at the sheets.
Major goals for the nursing care of clients with dementia should include what?
The client will be safe, be physiologically stable, and have infrequent episodes of agitation.
A group of friends have arrived at the hospital to visit a client recently diagnosed with delirium. The nurse tells the friends they can visit with the client one at a time. What is the likely reason for the nurse to give this instruction?
The nurse wants to prevent increasing the client's confusion.
The nurse preparing an educational program on dementia should include which information?
The onset of symptoms of dementia is gradual
After educating a group of nurses on Alzheimer's disease and appropriate nursing care, the group leader determines that the education was successful when the nurses identify which as the foundation for providing care to the client and family?
Therapeutic relationship
When assessing a client with dementia, a nurse identifies that the client is experiencing hallucinations. Based on the nurse's understanding of this disorder, which type of hallucination would the nurse expect as most common?
Visual
Which type of hallucination is most commonly seen in clients diagnosed with delirium?
Visual
Which type of hallucination most commonly occurs in clients diagnosed with dementia?
Visual
An older adult with no significant medical history is admitted to the hospital through the emergency department after hitting the client's head during a fall and fracturing the humerus. The client does not require surgery and will probably be discharged the following day. Should the nurse be concerned about delirium?
Yes, because of the head injury and medication
