mod 3

20. T he nurse assesses which of the following behaviors in a client in early Stage I Alzheimer's disease? Select all that apply:

1. Masks forgetful behavior [ ] 2. Has a slow reaction time 5. Becomes angry when challenged 20. 1. 2. 5. A client attempts to mask forgetful behavior, has a slow reaction time, and may become angry when challenged in early Stage I Alzheimer's disease. Repetitive storytelling, an inability to follow simple directions, and a change in eating patterns are behaviors exhibited in Stage II Alzheimer's.

17. DONEPEZIL

ARICEPT

Dementia risk factors

Advanced age and family hx!; Low SES and poor medical care

7. Which symptom should a nurse identify that would differentiadisorders from clients with pseudodementia (depression)?

C. Altered task performance ANS: C The nurse should identify that attention & concentration are impaired in neurocognitive disorder& not in pseudodementia (depression).

Dementia pharm: goals

Improve symptoms and reverse cognitive decline (ideally); Actually to slow memory loss

Dementia: late symptoms

Long term memory loss, unable to communicate, incontinence, no ADLs

Dementia: initial symptoms

Short term memory loss, language problems, disorientation, decrease in judgment, decrease in abstract thinking, changes in mood and personality, misplacing things

Dementia patho

Theories: cerebral atrophy, neuritic plaques, tangles; Neuronal death in hippocampus causes decrease in Ach; 4 A's: amnesia, aphasia, apraxia, agnosia; Primary or secondary (ex: AIDS

9. When assessing an older adult, the nurse should be alert to the clinical manifestations of depression that may be masked by other chronic conditions. The cardinal and primary behavior exhibited in the depressed older adult is

a loss of interest in previously pleasurable 1. Loss of interest in previously enjoyable activities and withdrawal are indicators to the nurse that the client may be clinically depressed and in need of further assessment. Inactivity, drinking alcohol, and crying may be indicative of depression or other chronic conditions, not just depression.

18. A nurse assesses clients who have endocrine disorders. Which assessment findings are paired correctly with the endocrine disorder? (Select all that apply.).

a. Excessive thyroid-stimulating hormone - Increased bone formation b. Excessive melanocyte-stimulating hormone - Darkening of the skin 18 A, B Thyroid-stimulating hormone targets thyroid tissue & stimulates the formation of bone. Melanocyte-stimulating hormone stimulates melanocytes & promotes pigmentation or the darkening of the skin. Parathyroid hormone stimulates bone resorption. Antidiuretic hormone targets the kidney & promotes water reabsorption, causing a decrease in urinary output. Adrenocorticotropic hormone targets the adrenal cortex & stimulates the synthesis & release of corticosteroids.

15. A nurse cares for a client who is prescribed a serum catecholamine test. Which action should the nurse take when obtaining the sample?

c. Place the sample on ice & send to the laboratory immediately. C A blood sample for catecholamine must be placed on ice & taken to the laboratory immediately. This sample is not urine, & therefore the first sample should not be discarded nor should preservatives be added to the sample. The nurse should use the appropriate tube & obtain the sample based on which drugs are administered, not dietary schedules

What is the best explanation for the need to treat concomittant depression when a client has Alzheimer's Disease?

d Depression worsens the dementia.

5. A nurse prepares to palpate a client's thyroid gland. Which action should the nurse take when performing this assessment?

d. Place the client in a sitting position with the chin tucked down. 5 D The client should be in a sitting position with the chin tucked down as the examiner standsbehind the client. The nurse feels for the thyroid isthmus while the client swallows & turns the head tothe right, & the nurse palpates the right lobe with the right hand. The technique is repeated in theopposite fashion for the left lobe.

MEMANTINE

NAMENDA

TACRINE

COGNEX

11. Before preparing to use the Mini-Mental State Exam for cognitive function in an older adult, the nurse should consider which of the following limitations of the exam?

2. T he client must be able to see and write 2. T he Mini-Mental State Exam does not require a specially trained individual and requires only 20 to 30 minutes to administer. The client must be able to see and write because the client will be asked to write a sentence as well as to copy a drawn figure.

Delirium characteristics

4 cardinal signs: 1 acute/fluctuating, inattention, disorganized thinking, change in LOC; 2 Cognitive/perceptual disturbances: illusions and hallucinations; 3 Autonomic hyperactivity (increase in VS); 4 Hypervigilance, labile mood, anger/agitation; Can be life-threatening

4.4. A nurse assesses a client who is prescribed a medication that stimulates beta1 receptors. Which assessment finding should alert the nurse to urgently contact the health care provider?

4. A nurse assesses a client who is prescribed a medication that stimulates beta1 receptors. Which assessment finding should alert the nurse to urgently contact the health care provider? 4 A Stimulation of beta1 receptor sites in the heart has positive chronotropic & inotropic actions. Thenurse expects an increase in heart rate & increased cardiac output. The client with a heart rate of 50(c) MyStudyGroup101 LLC563beats/min would be cause for concern because this would indicate that the client was not respondingto the medication. The other vital signs are within normal limits & do not indicate a negative responseto the medication

10. Dementia pharm: Cholinesterase inhibitors

For mild to moderate, except aricept; Do not delay disease progression; Improvements modest and short; Start low, go slow!; AE: bronchoconstriction (COPD/asthma); Avoid antihistamines, TCAs, conventional antipschotics

Delerium Management

Reorient,

3. A nurse cares for a client with excessive production of thyrocalcitonin (calcitonin). For which electrolyte imbalance should the nurse assess?

c. Calcium C Parafollicular cells produce thyrocalcitonin (calcitonin), which regulates serum calcium levels.Calcitonin has no impact on potassium, sodium, or magnesium balances.

A nurse teaches an older adult with a decreased production of estrogen. Which statement should the nurse include in this client's teaching to decrease injury?

"Walk around the neighborhood for daily exercise." 14 B An older adult client with decreased production of estrogen is at risk for decreased bone density & fractures. The nurse should encourage the client to participate in weight-bearing exercises such as walking. Drinking fluids & performing perineal care will decrease vaginal drying but not decrease injury. Older adults often have a decreased glucose tolerance, but this is not related to a decrease in estrogen.

12. T he nurse should consider which of the following medical etiologies in an older adult who has been healthy until recently but has developed dementia?

1. Sexually transmitted diseases 1. T he first indication that a client has a sexually transmitted disease such as tertiary syphilis or HIV may be cognitive function changes and dementia.

35. While assessing a client diagnosed with dementia, the nurse notes that her husband is concernedabout what he should do when she uses vulgar language with him. The nurse should:

1. Tell her that she is very rude 35. 1 Because of the client's short-term memory impairment, the nurse gently corrects the client by stating her name and who she is. This approach decreases anxiety, embarrassment, and shame and maintains the client's self-esteem. Telling the client that she knows who the nurse is or that she forgot can elicit feelings of embarrassment and shame. Saying, "I told you already" sounds condescending, as if blaming the client for not remembering.

15. The nurse is caring for an older adult with situational depression following the death of a spouse. What is the most important outcome for the nurse to plan for?

1. The client will discuss the spouse and the meaning of the loss 1. It is most appropriate for the nurse to encourage clients who are experiencing situational depression over the loss of a spouse to verbalize their feelings. Crying is a normal and healthy expression of loss. The relationship with the spouse may not always have been positive, or the client may feel angry about the death. Setting an outcome that the client will speak positively describes how the client should feel and is not necessarily true.

. Which goals should be included in the plan of care for a client with dementia? SELECT ALL THATAPPLY

1. The client will remain physically safe. 2. The client will receive emotional support .3. The client will receive physical health care. 5. The client will function at highest level ofindependence 1, 2, 3, 5 The care of a client with dementia should include provisions for physical and emotional well-being and safety. The nurse should encourage and support the client's independence within the limit of his or her abilities. Alzheimer-type dementia is characterized by a progressive loss of both (c) MyStudyGroup101 LLC 537 physical and cognitive function. Therefore, improvement and/or independent living are not realistic goals.

10. A client is displaying behaviors consistent with stage 2 Alzheimer's disease. The client can no longerrecognize family members and requires assistance with personal hygiene and dressing. The client isfrequently incontinent of both urine and feces and displays violent outbursts during these times.Which nursing diagnoses should the nurse give highest priority to when developing the client's careplan?

1. Violence: directed at self or others 10. 1 The nurse should give the highest priority to diagnoses of violence. Safety is the first priority for any client. The client's memory loss and violent outbursts pose safety issues for both the client and others. While the other diagnoses are appropriate for this client, they do not have priority over the client's safety and the safety of others.

Dementia pharm: Aricept

1x dosing, extended release; Less peripheral AE; FOR SEVERE AD; Don't discontinue abruptly

18. A n 80-year-old client is admitted to the intensive care unit because of hemorrhaging after a stent is placed in her left femoral artery to improve circulation to the leg. The client is confused, not following instructions, and pulling at the intravenous tubing and indwelling catheter. The client's adult son tells the nurse, "My mom was never like this before. What have you done to her?" The best initial response the nurse can make is which of the following?

2. "Older adults will become confused after a bleed to the brain from decreased oxygen." 2. Older adult clients may become confused after a bleed to the brain from decreased oxygen. Telling the family that the medical team has done nothing to the client is a defensive statement and would cut off communication. Dementia is a medical diagnosis, which the nurse does not make. The best initial response by the nurse is to answer the son's question. The nurse may need to know if the client has an alcohol abuse problem, but not until the son's concerns are answered. Passing the son off to the physician at this point would shut down communication with the son.

13. Which of the following four older adult clients that the nurse is caring for does the nurse evaluate as most at risk for self-directed violence?

2. A widowed man who is 88 years old, lives alone, and has multiple chronic illnesses 2 Older women, even if depressed, tend to be less likely to harm themselves, because they have social support and other interests. Older men without social support who have multiple chronic illnesses and live alone are more likely to commit suicide than older women

19. An older client in a nursing facility suddenly becomes confused, paranoid, and verbally abusive to the staff. Which of the following is the priority nursing action?

2. Assess the vital signs and obtain a urine specimen 2. Assessing the vital signs and obtaining a urine specimen is the priority in an older client who suddenly becomes confused and develops psychotic behavior. A urinary tract infection would be evident from an elevated temperature and bacteria in the urine specimen.

25. The nurse monitors an older adult with Alzheimer's disease for which of the following adverse reactions to galantamine (Razadyne)? Select all that apply:

2. Bradycardia [ ] 3. Diarrhea 6. Anemia 2. 3. 6. Adverse reactions of galantamine (Razadyne) include bradycardia, diarrhea, and anemia. Other adverse reactions include nausea, vomiting, and weight loss.

16. Which of the following is the priority nursing intervention for the nurse to include in the plan of care for a client with behavior problems related to dementia?

2. Instruct the caregivers on the process of dementia and care to be given 2. Educating the caregivers, whether family members or others, is always the priority when caring for a client with dementia. The caregivers must understand the disease and expected behaviors as well as the interventions for problem behaviors. The same interventions may not be effective as the condition changes. This should be part of the continued evaluation and part of the replanning

GALANTAMINE

REMINYL

26. The registered nurse is planning the clinical assignments for a geriatric mental health unit. Which of the following assignments should the nurse delegate to a licensed practical nurse?

3. Administer donepezil hydrochloride (Aricept) to a client newly diagnosed with Alzheimer's disease 3. A licensed practical nurse may administer donepezil hydrochloride (Aricept) to a client with Alzheimer's disease. Developing a plan of care, performing a physical assessment, and providing education to a client's family on dementia are tasks that should be performed by a registered nurse.

22. Which of the following should the nurse include in the education provided to a new graduate nurse to protect the nurse from injury when a client with dementia or delirium becomes aggressive?

3. Provide a quiet, calm atmosphere and offer simple directions 3. Touching an agitated client may increase aggression and precipitate violence against the nurse. The client should be in a quiet, calm atmosphere away from others and simple directions should be offered. Offering a meal may work as a temporary distraction, but the client at this point will be unable to sit and follow instructions about eating.

24. Rivastigmine (Exelon) is prescribed for a client with dementia. Which of the following would be an appropriate outcome of nursing care specific to this drug? 1. The client will sleep 6 hours without waking during the night 2. The client will eat 50% of all meals and snacks 3. The client will maintain a weight within the normal range 4. The client will maintain the serum potassium within normal range

3. The client will maintain a weight within the normal range 3. Rivastigmine tartrate is used in the treatment of mild to moderate Alzheimer's disease. Nausea, vomiting, anorexia, and abdominal pain are adverse reactions to Exelon. The nurse should monitor weight weekly. Eating 50% of the food offered may not be sufficient to maintain body weight.

17. A nurse observes a family member continually reminding a client in late Stage II Alzheimer's disease of the date and place. The client is adamant that it is 1922 and the North Pole. The nurse informs the family member that continually reminding the client of the date and place will result in

3. a catastrophic reaction 3. In late Stage II Alzheimer's disease there is no hope for memory return. Repeating reality orientation for the client whose reality is different may cause anxiety, anger, agitation, and a catastrophic reaction, such as running away or violence.

21.21. An older adult client with dementia becomes increasingly confused and wanders away from a long-term facility. The appropriate nursing action is to

3. follow the client and redirect from a safe distance. 3. When a client with dementia wanders away from a long-term care facility, the nurse should see if the client will return willingly with persuasion and redirection. If the client will not return, notifying law enforcement may be necessary, but the presence of law enforcement officials may also agitate and frighten the client. At no time should the nurse physically restrain the client alone or transport a client.

14. An older adult client with chronic depression tells the nurse, "Don't worry about me. I can manage the pain of my arthritis. The way I mix up my medications helps." The best initial response by the nurse is which of the following?

4. "Tell me what you take and how you mix them." 4. Clients with chronic illnesses and pain often adjust their own medications or add over-the-counter medications. A client's depression could be a result of the drugs or it could be the reason the client mixes medications. The nurse needs further information to identify risks for injury.

. A nurse is assessing a 78-year-old postoperative client who is exhibiting signs of delirium. The nurseobserves that the client is convinced that it is 1954 and is complaining about "the bugs in this hotel."The nurse's priority intervention should be to:

4. arrange for an unlicensed sitter to stay with the client. 4 The nurse's priority intervention should be to arrange for someone to stay with the client. The client's immediate safety is the primary concern, and constant observation is the best means of providing a safe environment for this client. While medication may become appropriate, it should not be the first response to manage a client's behavior. It does not address the issue of observing the client for safety. Transferring the client closer to the nursing station does not provide the constant observation that is most appropriate for the client at this time. Asking the client's family to stay may not be a realistic expectation.

. A geriatric nurse is teaching student nurses about the risk factors for development of delirium in olderadults. Which student statement indicates that learning has occurred?

A. "Taking multiple medications may lead to adverse interactions or toxicity. ANS: A The nurse should identify that taking multiple medications may lead to adverse reactions ortoxicity & put an older adult at risk for the development of delirium. Symptoms of delirium includedifficulty sustaining & shifting attention. The client with delirium is disoriented to time & place & may alsohave impaired memory

6. A nursing instructor is teaching about donepezil (Aricept). A student asks, "How does this work? Will thiscure Alzheimer's disease (AD)?" Which is the appropriate instructor reply?

A. "This medication delays the destruction of acetylcholine, a chemical in the brain necessary formemory processes. Although most effective in the early stages, it serves to delay, but not stop, theprogression of the AD. The most appropriate response by the instructor is to explain that donepezil (Aricept) delays thedestruction of acetylcholine, a chemical in the brain necessary for memory processes. Although mosteffective in the early stages, it serves to delay, but not stop, the progression of AD.

9. A client diagnosed with neurocognitive disorder exhibits progressive memory loss, diminished cognitive functioning, & verbal aggression upon experiencing frustration. Which nursing intervention is mostappropriate?

A. Schedule structured daily routines. NS: A The most appropriate nursing intervention for this client is to schedule structured daily routines. Astructured routine will reduce frustration & thereby reduce verbal aggression.

13. A client with a history of cerebrovascular accident (CVA) is brought to an emergency departmentexperiencing memory problems, confusion, & disorientation. On the basis of this client's assessmentdata, which diagnosis would the nurse expect the physician to assign?

B. Vascular neurocognitive disorder 13 ANS: B The nurse should expect that this client would be diagnosed with vascular neurocognitivedisorder (NCD), which is due to significant cerebrovascular disease. Vascular NCD often has an abruptonset. This disease often occurs in a fluctuating pattern of progression.

3. A client diagnosed with neurocognitive disorder due to Alzheimer's disease can no longer ambudoes not recognize family members, & communicates with agitated behaviors & incoherentverbalizations. The nurse recognizes these symptoms as indicative of which stage of the illness?

D. Late stage ANS: D The nurse should recognize that this client is in the late stage of Alzheimer's disease. The latestage is characterized by a severe cognitive decline.

12. A client diagnosed with a neurocognitive disorder is exhibiting behavioral problems on a daily basis. Atchange of shift, the client's behavior escalates from pacing to screaming & flailing. Initially, which actionshould a nurse implement in this situation?

C. Assess environmental triggers & potential unmet needs. 12 ANS: C The initial nursing action is to assess environmental triggers & potential unmet needs. Due to thecognitive decline experienced in a client diagnosed with neurocognitive disorder, communication skillsmay be limited. The client may become disoriented & frustrated.

8. At what time during a 24-hour period should a nurse expect clients with Alzheimer's disease to exhibitmore pronounced symptoms?

C. At twilight ANS: C The nurse should determine that clients with Alzheimer's disease exhibit more pronouncedsymptoms at twilight. Sundowning is the term used to describe the worsening of symptoms in the lateafternoon & evening.

5. A client is experiencing progressive changes in memory that have interfered with personal, social, &occupational functioning. The client exhibits poor judgment & has a short attention span. A nurse shouldrecognize these as classic signs of which condition?

C. Neurocognitive disorder ANS: C The nurse should recognize that the client is exhibiting signs of neurocognitive disorder (NCD). InNCD, impairment is evident in abstract thinking, judgment, & impulse control. Behavior may beuninhibited & inappropriate.

. A client diagnosed with neurocognitive disorder due to Alzheimer's disease has impairments ofmemory & judgment & is incapable of performing activities of daily living. Which nursing interventionshould take priority?

D. Assist with bathing & toileting The priority nursing intervention for this client is to assist with bathing & toileting. A client who isincapable of performing activities of daily living requires assistance in these areas to ensure health &safety.

Dementia definition

Gradual irreversible impairment in cognitive function,decline in social and occupational function, no change in LOC

14. An older client has recently moved to a nursing home. The client has trouble concentrating & sociallyisolates. A physician believes the client would benefit from medication therapy. Which medicationshould the nurse expect the physician to prescribe?

D. Sertraline (Zoloft) 14 ANS: D The nurse should expect the physician to prescribe sertraline (Zoloft) to improve the client'ssocial functioning & concentration levels. Sertraline (Zoloft) is an SSRI (selective serotonin reuptakeinhibitor) antidepressant. Depression is the most common mental illness in older adults & is oftenmisdiagnosed as neurocognitive disorder.

2. A client diagnosed with vascular dementia is discharged to home under the care of his wife. Whichinformation should cause the nurse to question the client's safety?

D. The client smokes one pack of cigarettes per day. ANS: D Forgetfulness is an early symptom of dementia that would alert the nurse to question the client'ssafety at home if the client smokes cigarettes. Vascular dementia is a clinical syndrome of dementiadue to significant cerebrovascular disease. The cause of vascular dementia is related to an interruptionof blood flow to the brain. High blood pressure & hypertension are significant factors in the etiology.

13. Dementia: Progressive symptoms

Dysphasia (inability to communicate), apraxia (loss of motor coordination), visual agnosia (can't recognize things), dysgraphia, wandering

19. RIVASTIGMINE

EXELON

RIVASTIGMINE TRANSDERMAL

EXELON PATCH

16. Communication strategies with dementia

Identify yourself, maintain face-to-face, encourage reminiscing, talk about familiar things, be 1-2 arms lengths, use visuals, engage in activities

Which of the following would not be an appropriate outcome for an elderly client experiencing depression? [

Increased preoccupation with death and dying

An elderly client with depression will often exhibit self-deprecating thoughts. Which of the following nursing diagnoses would be most appropriate to address this behavior?

Low self-esteem related to irrational guilt feelings and obsessive thoughts

Dementia Dx

Mini mental status exam, H&P, imaging is not Dx, just shows progression

Dementia pharm: Memantine

Neuronal receptor blockerr; NMDA antagonist; Moderate-severe AD; Regulates glutamate; Better tolerated than cholinesterase inhibitors

Delerium definition

Organic brain syndrome SECONDARY to underlying cause

Dementia Dx

PET, CT, MRI, decrease in brain weight; Only confirmed after autopsy

Which of the following statements is an accurate fact related to the treatment of schizophrenia in the older adult?]

The elderly require smaller doses of neuroleptic medication to manage their psychotic symptoms.

10. Donepezil hydrochloride (Aricept) has been prescribed for a client with Alzheimer's disease. Which of the following adverse reactions should the nurse include in the medication instructions given to the family? Select all that apply:

] 1. Headache[ ] 6. Anorexia[ ] 3. Insomnia 1. 3. 6. Donepezil hydrochloride (Aricept) is used in the treatment of mild to moderate Alzheimer's disease. Adverse reactions of Aricept include Headache, bradycardia, insomnia, hypertension, diarrhea, and anorexia.

13. A nurse assesses a client diagnosed with adrenal hypofunction. Which client statement should the nurse correlate with this diagnosis?

a. "I have a terrible craving for potato chips." 13 A The nurse correlates a client's salt craving with adrenal hypofunction. Excessive thirst is related to diabetes insipidus or diabetes mellitus. Clients who have hypothyroidism often have a decrease in appetite. Excessive hunger is associated with diabetes mellitus

6. A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is prescribed a 24-hour urine specimen collection. Which statement should the nurse include when delegating this activity to the UAP?

a. "Note the time of the client's first void & collect urine for 24 hours." 6 A The collection of a 24-hour urine specimen is often delegated to a UAP. The nurse must ensurethat the UAP understands the proper process for collecting the urine. The 24-hour urine collectionspecimen is started after the client's first urination. The first urine specimen is discarded because there isno way to know how long it has been in the bladder, but the time of the client's first void is noted. Theclient adds all urine voided after that first discarded specimen during the next 24 hours. When the 24-hour mark is reached, the client voids one last time & adds this specimen to the collection. Thepreservative, if used, must be added to the container at the beginning of the collection. All urinesamples need to be collected for the test results to be accurate

8. A nurse teaches a client who has been prescribed a 24-hour urine collection to measure excreted hormones. The client asks, "Why do I need to collect urine for 24 hours instead of providing a random specimen?" How should the nurse respond?

a. "This test will assess for a hormone secreted on a circadian rhythm." 8 A Some hormones are secreted in a pulsatile, or circadian, cycle. When testing for these substances, a collection that occurs over 24 hours will most accurately reflect hormone secretion. Dilution of hormones in urine, secretion of hormone amounts, & ability to collect the correct hormone are not reasons to complete a 24-hour urine test.

10. A nurse cares for a client who is prescribed a 24-hour urine collection. The unlicensed assistive personnel (UAP) reports that, while pouring urine into the collection container, some urine splashed his hand. Which action should the nurse take next?

a. Ask the UAP if he washed his hands afterward 10 A For safety, the nurse should find out if the UAP washed his or her hands. The UAP should do this for two reasons. First, it is part of Standard Precautions to wash hands after client care. Second, if the container did have preservative in it, this would wash it away. The preservative may be caustic to the skin. The nurse can call the laboratory while the UAP is washing hands, if needed. The UAP would then need to fill out an incident or exposure report & may or may not need to go to Employee Health. The UAP also needs further education on Standard Precautions, which include wearing gloves.

16. A nurse cares for clients with hormone disorders. Which are common key features of hormones? (Select all that apply.)

a. Hormones may travel long distances to get to their target tissues. b. Continued hormone activity requires continued production & secretion. c. Control of hormone activity is caused by negative feedback mechanisms. A, B, C Hormones are secreted by endocrine glands & travel through the body to reach their target tissues. Hormone activity can increase or decrease according to the body's needs, & continued (c) MyStudyGroup101 LLC 564 hormone activity requires continued production & secretion. Control is maintained via negative feedback. Hormones are not stored for later use, & they do not alter genetic activity.

2. A nurse cares for a client with a deficiency of aldosterone. Which assessment finding should the nurse correlate with this deficiency?

a. Increased urine output A Aldosterone, the major mineralocorticoid, maintains extracellular fluid volume. It promotessodium & water reabsorption & potassium excretion in the kidney tubules. A client with an aldosteronedeficiency will have increased urine output. Vasoconstriction is not related. These sodium & glucoselevels are normal; in aldosterone deficiency, the client would have hyponatremia & hyperkalemia

17. A nurse cares for a client with a hypofunctioning anterior pituitary gland. Which hormones should the nurse expect to be affected by this condition? (Select all that apply.)

a. Thyroid-stimulating hormone c. Follicle-stimulating hormone e. Growth hormone 17 A, C, E Thyroid-stimulating hormone, follicle-stimulating hormone, & growth hormone all are secreted by the anterior pituitary gland. Vasopressin is secreted from the posterior pituitary gland. Calcitonin is secreted from the thyroid gland.

1. A nurse cares for a client who is prescribed a drug that blocks a hormone's receptor site. Which therapeutic effect should the nurse expect?

b. Decreased hormone activity B Hormones cause activity in the target tissues by binding with their specific cellular receptor sites,thereby changing the activity of the cell. When receptor sites are occupied by other substances thatblock hormone binding, the cell's response is the same as when the level of the hormone is decreased

12. A nurse cares for a client who has excessive catecholamine release. Which assessment finding should the nurse correlate with this condition?

b. Increased pulse 12 B Catecholamines are responsible for the fight-or-flight stress response. Activation of the sympathetic nervous system can be correlated with tachycardia. Catecholamines do not decrease blood pressure or respiratory rate, nor do they increase urine output

9. A nurse plans care for an older adult who is admitted to the hospital for pneumonia. The client has no known drug allergies & no significant health history. Which action should the nurse include in this client's plan of care?

b. Offer fluids every hour or two. 9 B A normal age-related endocrine change is decreased antidiuretic hormone (ADH) production. This results in a more diluted urine output, which can lead to dehydration. If no contraindications are known, the nurse should offer (or delegate) the client something to drink at least every 2 hours. A client with simple pneumonia would not require Airborne Precautions. Indwelling urinary catheterization is not necessary for this client & would increase the client's risk for infection. The nurse should plan a toileting schedule & assist the client to the bathroom if needed. Palpating the client's thyroid gland is a part of a comprehensive examination but is not specifically related to this client.

7. A nurse assesses a female client who presents with hirsutism. Which question should the nurse ask when assessing this client?

b."How do you feel about yourself?" 7 B Hirsutism, or excessive hair growth on the face & body, can result from endocrine disorders. Thismay cause a disruption in body image, especially for female clients. The nurse should inquire into theclient's body image & self-perception. Asking about the client's financial status or current medicationsdoes not address the client's immediate problem. The client is not doing anything to herself to causethe problem, nor can the client prevent it from happening

23. Donepezil hydrochloride (Aricept) is prescribed for an older adult with early dementia, Alzheimer'slike disease (ALD). When reviewing the client's medical conditions and medications, the nurse notifies the physician that there might be a serious interaction because the client has

bradycardia. 4. Aricept is a cholinesterase inhibitor used in the treatment of Alzheimer's disease, which may cause bradycardia with fainting.

10 A client says, "I have been told I have pseudodementia. I guess that means I am just pretending to be crazy. Maybe it is some kind of an unconscious thing." The nurse should evaluate this statement as an indication the client needs

c further information about pseudodementia

11. A nurse evaluates laboratory results for a male client who reports fluid secretion from his breasts. Which hormone value should the nurse assess first?

c. Anterior pituitary hormones C Breast fluid & milk production are induced by the presence of prolactin, secreted from the anterior pituitary gland. The other hormones would not cause fluid secretion from the client's breast.

When an older adult male patient with depression complains of feelings of hopelessness and worthlessness, which of these nursing interventions would be most therapeutic?

d Reminiscence therapy and life review

An elderly client is experiencing depression in the nursing home. Which of the following statements is true regarding the symptoms of depression in older adults?

d Somatization is a common sign of depression in older adults.

3Whenever a nurse approaches a cognitively impaired client to assist the client to change clothes, the client yells, "NO!" and tries to push the nurse away. The nurse should plan to

d step back from the client, wait a few moments, and begin the process again.

When assessing a client with Huntington's Disease for chorea, the nurse should look for

vinvoluntary, purposeless, rapid movement

12. An elderly woman's husband died. When her brother arrives for the funeral, he notices her shortterm memory problems and occasional disorientation. A few weeks later, she calls him to say thather husband just died. She says, "I didn't know he was so sick. Why did he die now?" She alsocomplains of not sleeping, urinary frequency and burning, and seeing rats in the kitchen. A homecare nurse is sent to evaluate her situation and finds the woman reclusive and passive, but pleasant.The nurse calls the woman's primary care physician to discuss the client's situation and background,and give his assessment and recommendations. The nurse concludes that the woman:

is experiencing delirium and a urinary tract infection. 12. 4 Delirium is commonly due to a medical condition such as a UTI in the elderly. Delirium often involves memory problems, disorientation, and hallucinations. It develops rather quickly. There is not enough data to suggest Alzheimer's disease especially given the quick onset of symptoms. Delayed grieving and adjusting to being alone are unlikely to cause hallucinations

During the admission of a client with late Stage 2 Alzheimer's disease to a long-term care facility, the family asks if they should visit the client. Which statement by the client's spouse would indicate an accurate understanding of the family's role in this new situation?

"If I want, I can visit and help with the things we have been doing."

52. When developing a teaching plan for the community about managed care models and their effect on clients with chronic mental illnesses, which of the following factors should the nurse include as detrimental to this population? Select all that apply.

1. Restriction in the range and quantity of services. 3. Non-shifting funding to outpatient services when clients are moved to these services. 52. 1, 3 Without a sufficient range and quantity of services, care is inadequate and hospitalization rates increase. Non-shifting of allocated funding to outpatient services has increased the problem with the range and quantity of services. Reserving hospitalization for emergency services was a practice before managed care. The principle of "least restrictive alternative" is still as relevant as it was before managed care. There are not enough group homes available.

3. A nurse is visiting the home of a client diagnosed with Alzheimer's disease. The nurse assesses thestress level of the client's spouse, the primary caregiver. Which question is most appropriate forassessing the spouse's stress level?

1. "So, what is a typical day like for you?" 1 The nurse should ask the client's wife to describe a typical day. Using an open-ended questioning technique provides the client's wife with an opportunity to share any information she feels appropriate. Based on the information provided, the nurse can then ask questions that are more specific to the areas of concern. Option 2 presumes that the client's wife is experiencing stress and may cause her to become defensive. Option 3 is a close-ended question that limits the discussion. Option 4 again presumes that the wife is experiencing stress and limits discussion since it requires only a yes or no answer.

8. An older adult's cognitive function has declined over the last 2 years. The family is concerned by the loss of short-term memory and the safety issues posed by the forgetfulness. A complete medical workup including a computerized tomography (CT) scan of the head has shown no medical cause for the cognitive changes. The nurse explains to the client and family that the medical diagnosis of Alzheimer's disease is based on

1. the information that no other cause can be found for the changes. 1. T he definitive diagnosis for Alzheimer's disease is only found on autopsy. When all other possible causes of cognitive decline are ruled out, the medical diagnosis of Alzheimer's disease (or Alzheimer's-like disease) is made. The Mini-Mental State Exam is one of many short tests to measure cognitive function, but it does not actually diagnose dementia. The older adult will show a decrease in the mass of the brain but may not have a corresponding loss of cognitive function. A blood test for C-reactive protein would not be positive for Alzheimer's disease.

5. An 86-year-old client suddenly becomes confused about time, place, and person. After evaluating the oxygen saturation to be 98%, which of the following should the nurse assess first?

2. Vital signs I n the case of delirium and a sudden change in mental status, the nurse should always assess for physiological causes—airway, breathing, and circulation—first. Although medications the client is (c) MyStudyGroup101 LLC 552 taking, a recent fall, or the client's pain level may be possible causes of the delirium, the vital signs should be assessed first.

9. A client with dementia who prefers to stay in his room has been brought to the dayroom. After 10minutes, the client becomes agitated and retreats to his room again. The nurse decides to assess theconditions in the dayroom. Which is the most likely occurrence that is disturbing to this client?

3. A relaxation tape is playing in one corner of the room, and a television airing a special on crimeis playing in the opposite corner. 29. 3 The tape and television are competing, even conflicting, stimuli. Crime events portrayed on television could be misperceived as a real threat to the client. A low number of clients and the presence of a few staff members quietly working are less intense stimuli for the client and not likely to be disturbing.

24. Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a clientwith delirium?

3. Regain orientation to time and place. 24. 3 In approximately 2 to 3 days, the client should be able to regain orientation and thus become oriented to time and place. Being able to explain the experience of having delirium is something that the client is expected to achieve later in the course of the illness, but ultimately before discharge. Resuming a normal sleep-wake cycle and establishing normal bowel and bladder function probably will take longer, depending on how long it takes to resolve the underlying condition.

38. While educating the daughter of a client with dementia about the illness, the daughter complainsto the nurse that her mother distorts things. The nurse understands that the daughter needs furtherteaching about dementia when she makes which statement?

4. "I tell her she is wrong and then I tell her what's right. 38. 4 Telling the client that she is wrong and then telling her what is right is argumentative and challenging. Arguing with or challenging distortions is least effective because it increases defensiveness. Telling the client about reality indicates awareness of the issues and is appropriate. Acknowledging that misperceptions are part of the disease indicates an understanding of the disease and an awareness of the issues. Turning off the radio helps to limit environmental stimuli and indicates an awareness of the issues.

14. The son of an elderly client who has cognitive impairments approaches the nurse and says, "I'm soupset. The physician says I have 4 days to decide on where my dad is going to live." The nurseresponds to the son's concerns, gives him a list of types of living arrangements, and discusses theneeds, abilities, and limitations of the client. The nurse should intervene further if the son makes whichcomment?

4. "I want the social worker to make this decision so Dad won't blame me." 14. 4 Expecting the social worker to make the decision indicates that the son is avoiding participating in decisions about his father. The other responses convey that the son understands the importance of a careful decision, the availability of resources, and the ability to make new plans if needed.

46. The nurse determines that the son of a client with Alzheimer's disease needs further educationabout the disease when he makes which of the following statements?

4. "I woke up this morning expecting that my old Dad would be back. The statement about expecting that the old Dad would be back conveys a lack of acceptance of the irreversible nature of the disease. The statement about not realizing that the deterioration would be so incapacitating is based in reality. The statement about the Alzheimer's group is based in reality and demonstrates the son's involvement with managing the disease. Stating that reminiscing is important reflects a realistic interpretation on the son's part

51. A client reports having blurred vision after 4 days of taking haloperidol (Haldol) 1 mg. BID, and benztropine (Cogentin) 2 mg BID. The nurse contacts the physician to explain the situation, background, assessment and make a recommendation. Which information reported to the physician is the assessment of the situation?

4. "The higher dose of Cogentin could be causing Mr. Roberts' blurred vision." 51. 4 Cogentin has a common side effect of blurred vision. After evaluating the relative doses of Haldol and Cogentin, the assessment would be that the higher dose of Cogentin compared to the dose of Haldol is responsible for the blurred vision. (High doses of Haldol can cause blurred vision at times.) Reporting that Mr. Roberts has blurred vision is the situation. Listing the medications and doses is describing the background. The recommendation would be a lower dose of Cogentin.

2. A family expresses concern to the nurse when their 96-year-old mother with dementia living in a longterm care facility seems more confused and does not remember the activities of daily living. Which of the following is the most appropriate response?

4. "This must be frustrating for you." 4. W hen a family expresses concern over their mother's confusion and decreased ability to perform her activities of daily living, the most appropriate response to the family is to acknowledge how frustrating it must be for the family. The nurse should not minimize family members' feelings or tell them how to feel. Reminding a client with short-term memory loss may increase agitation. Although the dementia will progress over time, reinforcing that with the family is a negative response and may shut down communication.

50. When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant?

4. Maintain consistency in environment, routine, and caregivers 50. 4 Change increases stress. Therefore, the most important and relevant suggestion is to maintain consistency in the client's environment, routine, and caregivers. Although rest periods are important, going to bed interferes with the sleep-wake cycle. Rest in a recliner chair is more useful. Testing cognitive functioning and reality orientation are not likely to be successful and may increase stress if memory loss is severe

10. After 1 week of continuous mental confusion, an elderly African American client is admitted with apreliminary diagnosis of major neurocognitive disorder due to Alzheimer's disease. What should causethe nurse to question this diagnosis?

C. Neurocognitive disorder does not develop suddenly. ANS: C The nurse should know that neurocognitive disorder (NCD) does not develop suddenly &should question this diagnosis. The onset of NCD symptoms is slow & insidious & is unrelated to race,culture, or creed. The disease is generally progressive & debilitating.

1 . A client's spouse hands a pair of bedroom slippers to the client. The client looks confused and asks, "What are these? Who are you?" Which of the following should be the client's nursing diagnosis?

a Altered thought processes (Agnosia)

In your evaluation of an elderly male, widowed client with depression, what would be particularly important to include in the care of this client to ensure his safety?

a Assessment of suicide risk and degree of lethality

A client with dementia is a resident in a long term facility. During a music therapy session, the client starts to cry and indicates that it is 1931 and no one wants to dance at the high school prom. What action should the nurse take?

a Encourage the client to talk about music and dancing

. During the initial assessment of a client diagnosed as having Pick's disease, the nurse asked, "What does it mean when people say, 'A bird in the hand is worth two in the bush'?" This questions reflects the nurses attempt to assess

a abstract reasoning.

The family of a cognitively impaired client asks for assistance in planning how to cope with the client's wandering and inability to sleep at night. The nurse should instruct the family to

a allow the client to wander in a safe area until sleepy

2 . An elderly client is extremely confused following surgery. The confusion appears to be related to the medications and anesthesia the client has received. The client's family is very concerned and asks, "How will this all end?" The nurse should tell the family that

a the client will improve as the effects of the medications decrease.

10 . Which of these nursing communications would be most effective in teaching an older adult client about aging using a biologic theoretical framework?

b "The quality and quantity of fresh fruits and vegetables in your diet is important now so that your body is able to combat infection and diseases."

9 . An older adult client with a diagnosis of depression says, "Yesterday, I had a heck of a time remembering where I had parked my car in the shopping center. Am I getting Alzheimer's disease?" Which would be the best approach for the nurse to take?

b "When people are anxious or depressed, they can forget simple things like where they parked the car. Nevertheless, I will report your concerns to the doctor."

When an older adult client refuses to eat some meals, does not take some medications, and is distrustful of others, the client should be carefully assessed for which of the following?

b Delusional disorders

A cognitively impaired client sees a belt on a bed and becomes fearful. The client warns the nurse, "Watch out for that snake on the bed!" This behavior indicates the client has a problem with

b perception.

34. The client with dementia states to the nurse, "I know you. You're Margaret, the girl who lives downthe street from me." Which of the following responses by the nurse is most therapeutic?

2. "Now Mrs. Jones, you know who I am. 34. 2 Clients with chronic cognitive disorders experience defects in memory orientation and intellectual functions, such as judgment and discrimination. Loss of other abilities, such as speech, endurance, and balance, is less typical.

41. When developing the plan of care for a client with Alzheimer's disease who is experiencingmoderate impairment, which of the following types of care should the nurse expect to include?

. Prompting and guiding ADLs. 41. 1 Considerable assistance is associated with moderate impairment when the client cannot make decisions but can follow directions. Managing medications is needed even in mild impairment. Constant care is needed in the terminal phase, when the client cannot follow directions. Supervision of shaving is appropriate with mild impairment—that is, when the client still has motor function but lacks judgment about safety issues.

47. The husband of a client with Alzheimer's disease that was diagnosed 6 years ago approaches thenurse and says, "I'm so excited that my wife is starting to use donepezil (Aricept) for her illness." Thenurse should tell the husband:

. The medication is effective mostly in the early stages of the illness. 47. 1 When compared with other similar medications, donepezil (Aricept) has fewer adverse effects. Donepezil is effective primarily in the early stages of the disease. The drug helps to slow the progression of the disease if started in the early stages. After the client has been diagnosed for 6 years, improvement to the level seen 6 years ago is highly unlikely. Data are not available to support the drug's effectiveness for clients in the terminal phase of the disease.

55. The nurse manager of a psychiatric unit notices that one of the nurses commonly avoids a 75-yearold client's company. Which of the following factors should the nurse manager identify as being the most likely cause of this nurse's discomfort with older clients?

1. Fears and conflicts about aging. 55. 1 The most common reason for the nurse's discomfort with elderly clients is that she has not examined her own fears and conflicts about aging. Until nurses resolve their fears, it is unlikely that they will feel comfortable with elderly clients. A dislike of physical contact with older people, a desire to be surrounded by beauty and youth, and recent experiences with a parent's elderly friends are possible explanations, but not common or likely.

7. An older adult is picking at clothing and muttering, "Butterflies are all over me." The nurse does not see any butterflies. Which of the following is the priority for the nurse to perform?

1. Identify any risk for injury related to altered thought processes 1. T he first nursing action should be to identify any risks to the client or others because of the alteration in thought processes that the client is experiencing. It may be appropriate to provide a non-stimulating environment, but that is not the priority. Informing the client that there are no butterflies might precipitate a catastrophic reaction.

23. Which of the following is essential when caring for a client who is experiencing delirium?

2. Identifying the underlying causative condition or illness. 23. 2 The most critical aspect when caring for the client with delirium is to institute measures to correct the underlying causative condition or illness. Controlling behavioral symptoms with low-dose psychotropics, manipulating the environment, and decreasing or discontinuing all medications may be dangerous to the client's health.

18. An 83-year-old woman is admitted to the unit after being examined in the emergency department(ED) and diagnosed with delirium. After the admission interviews with the client and her grandson,the nurse explains that there will be more laboratory tests and X-rays done that day. The grandsonsays, "She has already been stuck several times and had a brain scan or something. Just give hersome medicine and let her rest." The nurse should tell the grandson which of the following? Select allthat apply.

1. "I agree she needs to rest, but there is no one specific medicine for your grandmother's condition."2. "The doctor will look at the results of those tests in the ED and decide what other tests are needed."3. "Delirium commonly results from underlying medical causes that we need to identify and correct." 18. 1, 2, 3 The client does need rest and it is true that there is no specific medicine for delirium, but it is crucial to identify and treat the underlying causes of delirium. Other tests will be based on the results of already completed tests. Although some medications may be prescribed to help the client with her behaviors, this is not the primary basis for medication orders. Because the underlying medical causes of delirium could be fatal, treatment must be initiated as soon as possible. It is not the nurse's role to determine medications for this client. Postponing tests until the next day is inappropriate.

19. The nurse is attempting to draw blood from a woman with a diagnosis of delirium who wasadmitted last evening. The client yells out, "Stop; leave me alone. What are you trying to do to me?What's happening to me?" Which response by the nurse is most appropriate?

1. "The tests of your blood will help us figure out what is happening to you." 19. 1 Explaining why blood is being taken responds to the client's concerns or fears about what is happening to her. Threatening more pain or promising to explain later ignores or postpones meeting the client's need for information. The client's statements Do not reflect loss of self control requiring medication intervention.

11. A home health nurse caring for a client diagnosed with Alzheimer's disease is attempting todetermine whether the client's daughter understands the client's prognosis. Which of the daughter'squestions to the nurse will most accurately assess the daughter's understanding of Alzheimer'sdisease and its prognosis?

1. "What types of support services are available?" 11. 1 The daughter's question about support services indicates an understanding that her father will experience increased cognitive impairment that will require the support of outside personnel and/or agencies. While current drug therapy delays the progressive deterioration of cognitive function, there may not be any apparent improvement for this chronic, irreversible, progressive disease. Therefore, questions related to improving memory and medications do not elicit the needed response. Being able to identify the best treatment program does not mean that the daughter understands the disease.

9. The client in the early stage of Alzheimer's disease and his adult son attend an appointment at thecommunity mental health center. While conversing with the nurse, the son states, "I'm tired ofhearing about how things were 30 years ago. Why does Dad always talk about the past?" The nurseshould tell the son

1. "Your dad lost his short-term memory, but he still has his long-term memory." 39. 1 The son's statements regarding his father's recalling past events is typical for family members of clients in the early stage of Alzheimer's disease, when recent memory is impaired. Telling the son to be more accepting is critical and not an attempt to educate. Understanding the client's level of anxiety is unrelated to the memory loss of Alzheimer's disease. The client cannot stop reminiscing at will.

13. In planning for the discharge of a client with a cognitive disorder, it is important to assess theclient's caregiver support system. Which aspects are the most crucial to assess? Select all that apply.

1. Availability of resources for caregiver support. 2. Ability to provide the level of care and supervision needed by the client. 3. Willingness to transport the client to medical and psychiatric services. 5. Willingness to install door alarms and make other safety changes. 6. Understanding the client's abilities and limitations 13. 1, 2, 3, 5, 6 It is important for a caregiver to have support for herself as well as be able to provide adequate safety, supervision, and medical care to the client. The caregiver must also have realistic expectations of the client, given his abilities and limitations. Reminiscing and engaging the client in games is desirable but not crucial to care.

26. A client has been in the critical care unit for 3 days following a severe myocardial infarction.Although he is medically stable, he has begun to have fluctuating episodes of consciousness,illogical thinking, and anxiety. He is picking at the air to "catch these baby angels fl ying around myhead." While waiting for medical and psychiatric consults, the nurse must intervene with the client'sneeds. Which of the following needs have the highest priority? Select all that apply.

1. Decreasing as much "foreign" stimuli as possible. 2. Avoiding challenging the client's perceptions about "baby angels." 4. Gently presenting reality as needed. 26. 1, 2, 4 The abnormal stimuli of the critical care unit can aggravate the symptoms of delirium. Arguing with hallucinations is inappropriate. When a client has illogical thinking, gently presenting reality is appropriate. Dementia is not the likely cause of the client's symptoms. The client is experiencing delirium, not dementia.

22. In addition to developing over a period of hours or days, the nurse should assess delirium asdistinguishable by which of the following characteristics?

1. Disturbances in cognition and consciousness that fluctuate during the day. 22. 1 Fluctuating symptoms are characteristic of delirium. The failure to identify objects despite intact sensory functions, significant impairment in social or occupational functioning over time, and memory impairment to the degree of being called amnesia all indicate dementia

25. Which of the following should the nurse expect to include as a priority in the plan of care for aclient with delirium based on the nurse's understanding about the disturbances in orientationassociated with this disorder?

1. Identifying self and making sure that the nurse has the client's attention. 25. 1 Identifying oneself and making sure that the nurse has the client's attention addresses the difficulties with focusing, orientation, and maintaining attention. Eliminating daytime napping is unrealistic until the cause of the delirium is determined and the client's ability to focus and maintain attention improves. Engaging the client in reminiscing and avoiding arguing are also unrealistic at this time.

45. When helping the families of clients with Alzheimer's disease cope with vulgar or sexual behaviors,which of the following suggestions is most helpful?

1. Ignore the behaviors, but try to identify the underlying need for the behaviors 45 1 The vulgar or sexual behaviors are commonly expressions of anger or more sensual needs that can be addressed directly. Therefore, the families should be encouraged to ignore the behaviors but attempt to identify their purpose. Then the purpose can be addressed, possibly leading to a decrease in the behaviors. Because of impaired cognitive function, the client is not likely to be able to process the inappropriateness of the behaviors if given feedback. Likewise, anger management strategies would be ineffective because the client would probably be unable to process the inappropriateness of the behaviors. Risperidone (Risperdal) may decrease agitation, but it does not improve social behaviors.

15. Transfer data for a client brought by ambulance to the hospital's psychiatric unit from a nursinghome indicate that the client has become increasingly confused and disoriented. The client'sbehavior is found to be the result of cerebral arteriosclerosis. Which of the following behaviors of thenursing staff should positively influence the client's behavior? Select all that apply.

1. Limiting the client's choices .2. Accepting the client as he is. 5. Explaining to the client what he needs to 15. 1, 2, 5. Confused clients need fewer choices, acceptance as a person, and step-by-step directions. Allowing the client to do as he wishes can lead to substandard care and the risk of harm. Acting nonchalantly conveys a lack of caring.

30. Nursing staff are trying to provide for the safety of an elderly female client with moderatedementia. She is wandering at night and has trouble keeping her balance. She has fallen twice buthas had no resulting injuries. The nurse should:

1. Move the client to a room near the nurse's station and install a bed alarm 30. 1 Using a bed alarm enables the staff to respond immediately if the client tries to get out of bed. Sleeping in a chair at the nurse's station interferes with the client's restful sleep and privacy. Using all four bedrails is considered a restraint and unsafe practice. It is not appropriate to expect a family member to stay all night with the client.

49. The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The clientrecently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the familyabout the use of lorazepam (Ativan). The nurse should instruct the family to report which of thefollowing significant side effects to the health care provider?

1. Paradoxical excitemen 49. 1 Although all of the side effects listed are possible with Ativan, paradoxical excitement is cause for immediate discontinuation of the medication. (Paradoxical excitement is the opposite reaction to Ativan than is expected.) The other side effects tend to be minor and usually are transient.

4. A client is in the late stage of Alzheimer's disease. To address the client's symptoms, which nursingintervention should take priority?

C. Promote dignity by providing comfort, safety, & self-care measure

17. A 69-year-old client is admitted and diagnosed with delirium. Later in the day, he tries to get out ofthe locked unit. He yells, "Unlock this door. I've got to go see my doctor. I just can't miss my monthlyFriday appointment." Which of the following responses by the nurse is most appropriate?

2. "It's Tuesday and you are in the hospital. I'm Anne, a nurse." 2 Loss of orientation, especially for time and place, is common in delirium. The nurse should orient the client by telling him the time, date, place, and who the client is with. Taking the client to his room and telling him why the door is locked does not address his disorientation. Telling the client to eat before going to the doctor reinforces his disorientation.

27. A nurse on the Gero-psychiatric unit receives a call from the son of a recently discharged client. Hereports that his father just got a prescription for memantine (Namenda) to take "on top of hisdonepezil (Aricept)." The son then asks, "Why does he have to take extra medicines?" The nurseshould tell the son:

2. "Namenda and Aricept are commonly used together to slow the progression of dementia." 27. 2 The two medicines are commonly given together. Neither medicine will improve dementia, but may slow the progression. Neither medicine is more effective than the other; they act differently in the brain. Both medicines have a half-life of 60 or more hours.

6. A nurse is assessing a client recently admitted into a psychiatric unit for observation. Which clientbehavior is indicative of impaired cognition?

2. Asking repeatedly, "How did I get here?" 2 The nurse should expect to observe the client becoming visibly agitated. Being physically restrained can be a humiliating and demoralizing experience. Typical responses to physical restraint include anger, anxiety, fear, depression, and stress-related responses. The client is more likely to be restless and experience insomnia with the potential for increased agitation, fear, and anxiety resulting in a heightened sense of pain. With the potential for increased agitation, fear, and anxiety, the client is more likely to have an increase in blood pressure.2 The client's disorientation is indicative of impaired cognition. Cognitive impairment can affect an individual's orientation to person, place, time, or memory of recent events. Mumbling is observed in clients with impaired cognition, but it can be a response to any number of situations, including anger, bewilderment, or experiencing hallucinations. Staring is seen in clients with impaired cognition, but it can be a response to any number of situations including fatigue and/or attempts at social isolation. Clients experiencing impaired cognition do not typically experience auditory hallucinations.

43. Which of the following is a priority to include in the plan of care for a client with Alzheimer's diseasewho is experiencing difficulty processing and completing complex tasks?

2. Asking the client to do one step of the task at a time. 43. 2 Because the client is experiencing difficulty processing and completing complex tasks, thepriority is to provide the client with only one step at a time, thereby breaking the task up into simple steps, ones that the client can process. Repeating the directions until the client follows them or demonstrating how to do the task is still too overwhelming to the client because of the multiple steps involved. Although maintaining structure and routine is important, it is unrelated to task completion.

28. A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. Toensure the client's safety while walking in the halls, the nurse should do which of the following?

2. Assess the client's gait for steadiness 28. 2 Elderly clients have increased risk for falls due to balance problems, medication use, and decreased eyesight. Haldol may cause extrapyramidal side effects (EPSE) which increase the risk for falls. The client is not agitated, so restraints are not indicated. Ativan may increase fall risk and cause paradoxical excitement.

1. T he nurse has determined that a confused older adult client who keeps pulling out the intravenous line and indwelling catheter is in need of soft wrist restraints. Which of the following should the nurse include in this client's plan of care?

2. Assess the placement of the wrist restraints, skin, and circulation every hour and document 1. 2. T he standard of care for restraints is that they can be applied only with a written order from a health care provider. The order must be renewed every 24 hours. A p.r.n. order for restraints is not acceptable. Restraints should be removed once every 2 hours to perform activities of daily living. The client with wrist restraints should be placed in a lateral position to prevent aspiration. The condition of the skin, circulation, and placement of restraints must be assessed every hour. The assessment must also be documented.

36. The term motor apraxia relates to a decline in motor patterns essential for complex motor tasks.However, the client with severe dementia may be able to perform which of the following actions?

2. Brush the teeth when handed a toothbrush. 36. 2 Vulgar language is common in clients with dementia when they are having trouble communicating about a topic. Ignoring the vulgarity and distracting her is appropriate. Telling the client she is rude or to stop swearing will have no lasting effect and may cause agitation. Just leaving the room is abandonment that the client will not understand.

54. A nurse is planning care for an elderly client with cognitive impairment who is still living at home. Which action should the nurse identify as a priority for safety in planning care for this client?

2. Ensuring the removal of objects in the client's path that may cause him to trip. 54. 2 When caring for a client with cognitive impairment, the priority is to ensure that all objects in the client's path are removed to prevent the client from falling. Additional measures, such as having two (c) MyStudyGroup101 LLC 542 people accompany the client when he ambulates, placing his favorite things in safekeeping, and giving medications in a liquid form to be sure he swallows them, are less crucial and available.

31. During a home visit to an elderly client with mild dementia, the client's daughter reports that shehas one major problem with her mother. She says, "She sleeps most of the day and is up most of thenight. I can't get a decent night's sleep anymore." Which suggestions should the nurse make to thedaughter? Select all that apply.

2. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime.3. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day.4. Promote relaxation before bedtime with a warm bath or relaxing music 31. 2, 3, 4 A set routine and brief exercises help decrease daytime sleeping. Decreasing caffeine and fluids and promoting relaxation at bedtime promote night time sleeping. A strong sleep medicine for an elderly client is contraindicated due to changes in metabolism, increased adverse effects, and the risk of falls. Using caffeinated beverages may stimulate metabolism but can also have longlasting adverse effects and may prevent sleep at bedtime; to stop swearing will have no lasting effect and may cause agitation. Just leaving the room is abandonment that the client will not understand.

1. A nurse engages an older adult client by describing the weather as "raining cats and dogs." Theclient looks bewildered and shows concern for the "animals." The nurse determines that the client isexhibiting concrete thinking. Which response by the nurse is most therapeutic?

2. Explain to the client that it is a way of saying it is raining heavily. 2 The most therapeutic response is to explain to the client that "raining cats and dogs" is a way of saying that it is raining heavily. A client who continually gives literal translations to verbal communication is exhibiting concrete thinking. Due to the client's inability to think in the abstract, care must be taken to avoid conversations that include abstract concepts. The nurse should attempt to clarify any confusion for the client. Even though option 1 addresses the client's concern for the well-being of the animals, it does not clarify the statement of "raining cats and dogs." While the staff needs to be aware of the client's limitation in understanding the abstract, alerting the staff does not address the issue of presenting information for the client in an acceptable manner. Documentation of the client's limitations is appropriate but does not address the issue of clarification of ideas and information.

42. The family of a client, diagnosed with Alzheimer's disease, wants to keep the client at home. Theysay that they have the most difficulty in managing his wandering. The nurse should instruct the familyto do which of the following? (Select all that apply).

2. Install motion and sound detectors. 4. Have the client wear a Medical Alert bracelet.5. Install door alarms and high door locks. 42. 2, 4, 5 Motion and sound detectors, a Medical Alert bracelet, and door alarms are all appropriate interventions for wandering. Sleep medications do not prevent wandering before and after the client is asleep and may have negative effects. Having a relative sit with the client is usually an unrealistic burden.

A 77-year-old client expresses concern to a nurse in a walk-in psychiatric clinic of "going crazy or of having Alzheimer's disease" because of feelings of being overwhelmed and sad all of the time, and misplacing things. Which of the following is the priority for the nurse to include in this client's plan of care?

2. Make a psychosocial assessment 2. T he first step of the nursing process is assessment. Before helping the client deal with a problem or exploring available resources, the nurse should determine if a problem is really present. Assuring the client and dispelling the idea of "going crazy" are negative interventions, and the nature of this client's condition is not yet known.

32. A client is experiencing agnosia as a result of vascular dementia. She is staring at dinner andutensils without trying to eat. Which intervention should the nurse attempt first?

2. Say, "It's time for you to start eating your dinner." 32. 2 Highly conditioned motor skills, such as brushing the teeth, may be retained by the client who has dementia and motor apraxia. Balancing a checkbook involves calculations, a complex skill that is lost with severe dementia. Confabulation is fabrication of details to fill a memory gap. This is more common when the client is aware of a memory problem, not when dementia is severe. Finding keys is a memory factor, not a motor function.

5. A client diagnosed with delirium is restrained in order to prevent the removal of a Foley catheterand an intravenous fluid line. Which response should the nurse expect after the client is restrained?

2. The client becomes visibly agitated 2 The nurse should expect to observe the client becoming visibly agitated. Being physically restrained can be a humiliating and demoralizing experience. Typical responses to physical restraint include anger, anxiety, fear, depression, and stress-related responses. The client is more likely to be restless and experience insomnia with the potential for increased agitation, fear, and anxiety resulting in a heightened sense of pain. With the potential for increased agitation, fear, and anxiety, the client is more likely to have an increase in blood pressure.

8. A nurse is caring for a client with a self-care deficit who exhibits behaviors associated withdementia. Which goals should be included in the plan of care for this client? SELECT ALL THAT APPLY

2. The client will consistently function at the highest possible level of personal independence. 5. The client's unmet hygiene needs will be addressed by members of the institution'smultidisciplinary health-care team. 6. The client's family will receive instructions on supporting the client's independence andpromoting self-care in regard to daily hygiene. 8. 2, 5, 6 The client's goals should be to function on the highest level of personal independence. The client's needs should be addressed by a team of health-care professionals with expertise in the areas related to the client. Supporting the family to encourage the client's independence contributes to the client's sense of control and well-being. While support in the form of sufficient time is appropriate, this response fails to address the fact that the client may never reach total independence. Assuming that the client will reach total independence may not be realistic. Not allowing for client autonomy by assisting with daily needs is not directed toward the client's best interest.

7. A nurse is caring for a client who states, "Lately I'm getting forgetful about things. I'm so afraid I'mgetting Alzheimer's disease." Which response by the nurse is most therapeutic?

3. "Although it's not unusual to experience some lapses of memory, let's discuss your concerns." 7. 3 The nurse is most therapeutic when attempting to discuss the client's concerns. With regard to memory functioning, the normal older adult will find that the time required for memory scanning is longer for both recent and remote memory recall. Dementia associated with Alzheimer's disease has a slow and insidious onset and is generally progressive and deteriorating in its course. The remaining responses provide false reassurance, which devalues the client's feelings, belittles valid concerns, and discourages the expression of feelings due to the anticipation of ridicule.

6. A 56-year-old client diagnosed with Stage I (early-onset) Alzheimer's disease lives at home with family. A daughter asks the nurse, "How long will Dad be like this before his memory returns?" The best initial response the nurse can make is which of the following?

3. "Tell me what you know about Alzheimer's disease T he best response when the family of a client diagnosed with Stage I (early-onset) Alzheimer's disease asks when the family member will get better would be to ask family members how much they know about Alzheimer's. This is the best response because it facilitates open communication. Although the disease has a progressive course, telling the family that will close communication. Asking the family member if the client is taking medication for Alzheimer's disease is an inappropriate response, because it changes the subject.

44. The client with Alzheimer's disease may have delusions about being harmed by staff and others.When the client expresses fear of being killed by staff, which of the following responses is mostappropriate?

3. "You are in the hospital. We are nurses trying to help you." 44. 3 The nurse needs to present reality without arguing with the delusions. Therefore, stating that the client is in the hospital and the nurses are trying to help is most appropriate. The client doesn't recognize the delusion or why it exists. Telling the client that the staff likes him too much to want to kill him is inappropriate because the client believes the delusions and doesn't know that they are false beliefs. It also restates the word, kill, which may reinforce the client's delusions. Telling the client not to be silly is condescending and disparaging and therefore inappropriate.

48. The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurseanticipates administering this medication to help decrease which of the following behaviors?

3. Agitation and assaultive-ness. 48. 3 Antipsychotics are most effective with agitation and assaultive-ness. Antipsychotics have little effect on sleep disturbances, concomitant depression, or confusion and withdrawal.

15. A client diagnosed with neurocognitive disorder due to Alzheimer's disease is disoriented & ataxic, &he wanders. Which is the priority nursing diagnosis?

C. Risk for injury 15 ANS: C The priority nursing diagnosis for this client is risk for injury. Both ataxia (muscular incoordination)& purposeless wandering place the client at an increased risk for injury.

16. The nurse observes a client in a group who is reminiscing about his past. Which effect should thenurse expect reminiscing to have on the client's functioning in the hospital?

3. Decrease the client's feelings of isolation and loneliness. 16. 3. Reminiscing can help reduce depression in an elderly client and lessens feelings of isolation and loneliness. Reminiscing encourages a focus on positive memories and accomplishments as well as shared memories with other clients. An increase in confusion and disorientation is most likely the result of other cognitive and situational factors, such as loss of short-term memory, not reminiscing. The client will not likely become sad because reminiscing helps the client connect with positive memories. Keeping the client from participating in therapeutic activities is less likely with reminiscing.

37. When communicating with the client who is experiencing dementia and exhibiting decreasedattention and increased confusion, which of the following interventions should the nurse employ asthe first step?

3. Eliminating distracting stimuli such as turning off the television 37. 3 Competing and excessive stimuli lead to sensory overload and confusion. Therefore, the nurse should first eliminate any distracting stimuli. After this is accomplished, then using touch and rephrasing questions are appropriate. Going for a walk while talking has little benefit on attention and confusion.

33. A client with early dementia exhibits disturbances in her mental awareness and orientation toreality. The nurse should expect to assess a loss of ability in which of the following other areas?

3. Endurance. 33. 3 Agnosia is the lack of recognition of objects and their purpose. The nurse should inform the client about the fork and what to do with it. Feeding the client does not address the agnosia or give the client specific directions. It should only be attempted if identifying the fork and explaining what to do with it is ineffective. Waiting for the family to care for the client is not appropriate unless identifying the fork and explaining or feeding the client are not successful.

21. When caring for the client diagnosed with delirium, which condition is the most important for thenurse to investigate?

3. Prescription drug intoxication. 21. 3 Polypharmacy is much more common in the elderly. Drug interactions increase the incidence of intoxication from prescribed medications, especially with combinations of analgesics, digoxin, diuretics, and anticholinergics. With drug intoxication, the onset of the delirium typically is quick. Although cancer, impaired hearing, and heart failure could lead to delirium in the elderly, the onset would be more gradual.

9. A cognitively impaired nursing home resident is beginning to show physical signs of agitation. Whichactivity would be most therapeutic to de-escalate the client's agitation?

3. Taking a walk outside with the nurse 9. 3 The most therapeutic activity would be to take a walk with the nurse. Structured activities will provide the client with a release for physical tension as well as an opportunity to build a trusting relationship with the nurse. Bingo is competitive, which may accelerate the client's agitation and thus place the client and the other residents in a potentially unsafe environment. The other responses fail to provide a structured outlet to promote de-escalation.

40. The nurse discusses the possibility of a client's attending day treatment for clients with earlyAlzheimer's disease. Which of the following is the best rationale for encouraging day treatment?

3. The client would benefit from increased social interaction 40. 3 The best rationale for day treatment for the client with Alzheimer's disease is the enhancement of social interactions. More daily structure, excellent staff, and allowing caregivers more time for themselves are all positive aspects, but they are less Focused on the client's needs.

20. A 90-year-old client diagnosed with major depression is suddenly experiencing sleep disturbances,inability to focus, poor recent memory, altered perceptions, and disorientation to time and place.Lab results indicate the client has a urinary tract infection and dehydration. After explaining thesituation and giving the background and assessment data, the nurse should make which of thefollowing recommendations to the client's physician?

4. A transfer of the client to a nursing home. 4 The client is showing symptoms of delirium, a common outcome of UTI in older adults. The nurse can request a transfer to a medical unit for acute medical intervention. The client's symptoms are not just due to a worsening of the depression. There are not indications that the client needs restraints or a transfer to a nursing home at this point.

4. Upon admission to a long-term care facility, an 83-year-old client is withdrawn, sitting quietly in a chair with the back to the door of the room. When the nurse speaks to the client, the client says, "Go away and leave me alone. Spend your time on someone who can use it. I just don't want to live if I have to stay here." Which of the following is the priority nursing action?

4. Assess for depression and suicide potential . Although creating a cheerful environment is important in a long-term care facility, the priority intervention is safety. Older adults who express not wanting to live if they have to stay there may be clinically depressed and at risk for self-harm. Encouraging clients to discuss feelings of hopelessness and allowing for periods of solitude may be appropriate interventions, but are not the priorities

53. When assessing an aggressive client, which of the following behaviors warrants the nurse's prompt reporting and use of safety precautions?

4. Naming another client as his adversary. 53. 4 The client exhibits aggression against his perceived adversary when he names another client as his adversary. The staff will need to watch him carefully for signs of impending violent behavior that may injure others. Crying about a divorce would be appropriate, not pathologic, behavior demonstrating grief over a loss. A petition to delay bedtime would be a positive, direct action aimed at a bothersome situation. Although declining to attend group therapy needs follow-up, there may be any number of unknown reasons for this action.

16. Which symptom should a nurse identify that would differentiate clients diagnosed with neurocognitivedisorders from clients diagnosed with amnesic disorders?

B. Neurocognitive disorders involve impairment of abstract thinking & judgment, whereas amnesticdisorders do not. 16 ANS: B Neurocognitive disorders involve impairment of abstract thinking & judgment. Amnesticdisorders are characterized by an inability to learn new information & to recall previously learnedinformation, with no impairment in higher cortical functioning or personality change.