211 Test 2

The use of a patient-centered interview technique works well for gathering information about abusive situations. It is a good use of clinical time to sit near the patient and: a. Establish trust and rapport b. Ask lots of questions c. Interrupt the patients' story to allow for decompression d. Utilize closed-ended questions

A

Twenty-four-hour observation is a good choice for restraint in which of the following patients? a. An inmate with suicidal ideation on hospice care b. A sex offender in the psychiatric intensive care unit c. An aggressive female with antisocial personality disorder d. An inmate diagnosed with paranoid schizophrenia

A

What is the rationale for providing a patient diagnosed with dementia easily accessible finger foods throughout the day? A) increases input throughout the day B) the person may be anorexic C) assists with monitoring food intake D) helps prevent constipation

A

When presenting the discharge teachings for a patient with dementia and Alzheimer disease, the daughter states, "My father wanders so much; I am afraid he'll slip away from me." Which dementia and Alzheimer disease resource would the nurse suggest to the daughter? A) Safe Return Program B) National Alzheimer's Group C) Alzheimer's Wandering Association D) Lost Family Members Tracking Association

A

Which statement made by a family member tends to support a diagnosis of delirium rather than dementia? A) she was fine last night but this morning she was confused B) dad doesn't seem to recognize us anymore C) She's convinced that snakes come into her room at night D) He can't remember when to take his pills or whether he's bathed

A

Which stage of Alzheimer disease would the nurse document when the patient demonstrates independent ADLs, has no social or employment difficulties, forgets names and misplaces items, and experiences short-term memory loss? A) One B) Two C) Three D) Four

A Characteristics of stage I Alzheimer disease include independence in ADLs, having no social problems, denying symptoms, and experiencing short-term memory loss. Those in stage II experience impairment of all cognitive functions but still exhibit some functional abilities. The patient in stage III of the disease is completely bedridden, totally dependent in ADLs, has lost motor and verbal skills, has generalized neurologic deficits, and has lost facial recognition. There are only three classifiable stages of Alzheimer disease.

A patient recently admitted to the hospital has been diagnosed with delirium. The family of the patient asks the nurse to explain what delirium is. How should the nurse respond? A) Delirium is reversible with treatment of the underlying cause. B) Delirium is progressive and has no known cure. C) Delirium affects a specific area of cognitive functioning. D) Delirium indicates the onset of a cerebrovascular accident.

A Delirium can be reversible with treatment of the precipitating problem and control of predisposing factors. Dementia is progressive and irreversible. Focal cognitive disorders affect a single area of cognitive functioning. Memory and orientation may be affected by a cerebrovascular accident (stroke), but delirium is not a sign of a stroke.

A 90-year-old patient is admitted to the hospital. Shortly after admission, the family notices that the patient is exhibiting disorientation and agitation. When the family asks the nurse about the behavior, the nurse states that the patient is at risk for developing which common complication of hospitalization in older adults? A) Delirium B) Dementia C) Alzheimer disease D) Sundowner syndrome

A Delirium, which occurs over hours to a few days, is the most frequent complication of hospitalization in the elderly population. Dementia occurs over a period of months. Alzheimer disease develops over months to years. Sundowner syndrome is most prominent in dementia and becomes worse in the evenings.

Which therapy would the nurse anticipate the primary health care provider prescribing for the older-adult patient with Alzheimer disease who presents with hallucinations and delusions? A) Neuroleptic agents B) Tricyclic antidepressants C) Cholinesterase inhibitors D) N-methyl-d-aspartate receptor antagonists

A Hallucinations and delusions are manifestations of emotional and behavioral health problems; when they occur alongside Alzheimer disease, neuroleptic agents may be used. Health care providers should avoid prescribing tricyclic antidepressants in older-adult patients with Alzheimer disease because of their anticholinergic effects. Health care providers may use cholinesterase inhibitors and N-methyl-d-aspartate receptor antagonists to treat Alzheimer disease and its symptoms, but these medications will not treat psychotic symptoms like hallucinations and delusions.

When the spouse of a patient with Alzheimer disease mentions a loving relationship and the required care as exhausting, which action would the home health nurse implement to alleviate the caregiver's stress? A) Arrange for respite care for the caregiver. B) Teach the patient improved self-care strategies. C) Provide positive reinforcement and support for the spouse. D) Restrain the patient for a short time each day to allow the wife to rest.

A Respite care can give the spouse some time to re-energize and will provide a social outlet for the patient. Providing positive reinforcement and support is encouraging but does not help the spouse's situation. Restraints are almost never appropriate and are used only as an absolute last resort. The patient with Alzheimer disease typically is unable to learn improved self-care.

Which is the priority action after the nurse observes human bite marks, cigarette burns, and bruises all over a patient's body? A) Conduct a survey based on the ABCDE mnemonic. B) Provide information about developing a safety plan. C) Coordinate with the crisis staff to assist the family of the victim. D) Collaborate with the rest of the staff to make a plan for the patient moving forward.

A The physical findings that the nurse observes are typical of intimate partner violence. When a victim of intimate partner violence is brought to the emergency department, the priority intervention is to conduct a survey based on the ABCDE mnemonic to determine any immediate threats to the patient's life. This assessment includes airway; breathing; circulation; disability; and exposure. Forensic nurse examiners (RN-FNEs) can help provide information about developing a safety plan to escape the violent relationship, but this is a lower priority than determining any immediate physical threats to the patient's life. Similarly, the nurse can coordinate with the crisis staff to assist family if necessary, and he or she can collaborate with the staff to make a plan for the patient moving forward, but these actions can happen after the patient's health has been stabilized

A community health nurse is preparing a course on protecting cognitive function. Which population group should the nurse target for teaching? A) Older male adults with diabetes B) Older female adults who are overweight C) Young adults living in school dormitories D) Adolescents attending summer camps

A The primary risk factor for cognitive impairment is advancing age; males with a history of stroke or diabetes are at significant risk. Older females with a history of poor health, insomnia, and lack of social support are at risk for cognitive impairment, not those who are overweight. Risk factors for young adults include substance abuse and high-risk behaviors, not crowded living conditions. Adolescents who attend summer camp are not necessarily at risk for cognitive problems; adolescents who participate in high-risk behaviors would be at risk.

For a patient beginning the discharge home process with progressive stage I Alzheimer disease, which priority action would the nurse implement to ensure continuity of care when the family expresses concern about providing care for the parent? A) Provide the name of the assigned case manager. B) Provide a safe home environment for the patient. C) Refer the family to the Alzheimer's Association. D) Answer all family questions before discharge

A Whenever possible, have a case manager assigned to the patient and family. The case manager can assess their needs for health care resources and facilitate appropriate placement throughout the continuum of care. Answering all family questions before discharge and providing a safe environment are necessary for family support but are not relevant for continuity of care. Referring the family to the Alzheimer's Association is necessary for appropriate resource referral but is not relevant for continuity of care.

Which intervention may help minimize relocation stress syndrome in an older adult? A) Encourage family to visit often. B) Limit patient decision making to decrease any anxiety. C) Avoid explaining procedures to patient to decrease anxiety. D) Change the patient's bathing schedule to night from morning

A Relocation stress syndrome is the physical and emotional distress that can occur when an older adult is moved into a long-term care facility. One way to minimize relocation stress is to encourage the family to visit the patient often. Allowing the patient to make their own decisions is preferable to all decisions being made for the patient. This allows the patient to maintain some control of their life. All procedures should be explained to the patient to decrease any anxiety associated with the procedures. Allowing the patient to maintain their daily routines is preferable to changing them.

Which factors tend to increase the difficulty of diagnosing young children who demonstrate behaviors associated with mental illness? Select all that apply. A) Limited language skills B) Level of cognitive development C) Level of emotional development D) Parental denial that a problem exists E) Severity of the typical mental illnesses observed in young children

A, B, C

The nurse is assisting a patient to identify safety issues that may occur now that she has left an abusive partner. What telephone numbers should be available to the patient? Select all that apply. a. The police department b. An abuse hotline c. A responsible friend or family member d. A domestic violence shelter e. The hospital emergency department

A, B, C, D

Which guidelines should direct nursing care when deescalating an angry patient? Select all that apply. a. Intervene as quickly as possible b. Identify the trigger for the anger c. Behave calmly and respectfully d. Recognize the patient's need for increased personal space e. Demands are agreed to as long as they won't result in harm to anyone

A, B, C, D

Which problem is observed in children who regularly witness acts of violence in their family? Select all that apply. a. Phobias b. Low self-esteem c. Major depressive disorder d. Narcissistic personality disorder e. Posttraumatic stress disorder

A, B, C, E

In pediatric mental health there is a lack of sufficient numbers of community-based resources and providers, and there are long waiting lists for services. This has resulted in: SATA A) Children of color and poor economic conditions being underserved B) increased stress in the family unit C) markedly increased funding D) premature termination of services

A, B, D

Which intervention(s) should the nurse implement when helping a patient expresses anger in an inappropriate manner? Select all that apply. a. Approach the patient in a calm, reassuring manner. b. Provide suggestions regarding acceptable ways of communicating anger. c. Warn the patient that being angry is not a healthy emotional state. d. Set limits on the angry behavior that will be tolerated. e. Allow any expression of anger as long as no one is hurt.

A, B, D

A family member of a patient admitted for delirium asks the nurse what the difference is between delirium and dementia. Which response would the nurse provide the family member? Select all that apply. A) "Delirium is reversible while dementia is irreversible." B) "Delirium is an acute condition while dementia is a chronic condition." C) "Delirium is associated with confusion while dementia only affects memory." D) "Delirium has known etiologic factors whereas the etiology of dementia is still being researched." E) "Delirium occurs more often in older adults whereas dementia occurs more often in young adults."

A, B, D Delirium is a reversible condition while dementia is irreversible. Delirium lasts for hours to 1 year while dementia lasts for months to years. Delirium has multiple etiologic factors including surgery, infection, and drugs while the etiology of dementia is still being researched. Both delirium and dementia are associated with confusion. Dementia occurs more often in older adults than in younger adults.

Perpetrators of domestic violence tend to: Select all that apply. a. Have relatively poor social skills and to have grown up with poor role models. b. Believe they, if male, should be dominant and in charge in relationships. c. Force their mates to work and expect them to handle the financial decisions. d. Be controlling and willing to use force to maintain their power in relationships. e. Prevent their mates from having relationships and activities outside the family.

A, B, D, E

Which individuals are most at risk for displaying aggressive behavior? Select all that apply. a. An adolescent embarrassed in front of friends. b. A young male who feels rejected by the social group. c. A young adult depressed after the death of a friend. d. A middle-aged adult who feels that concerns are going unheard. e. A patient who was discovered telling a lie.

A, B, D, E

Which signs and symptoms are associated with acute stress disorder and often observed in patients who have been sexually assaulted? Select all that apply. a. Outbursts of anger b. Depression c. Auditory hallucinations d. Flashbacks e. Amnesia for the event

A, B, D, E

Nurses caring for patients who have neurocognitive disorders are exposed to stress on many levels. Specialized skills training and continuing education are helpful to diffuse nursing stress, as well as: SATA A) Expressing emotions by journaling B) Describing stressful events on FB C) Engage in exercise and relaxation activities D) Having realistic patient expectations E) Happy hour after work to blow off steam

A, C, D

For family members of a patient diagnosed with Alzheimer disease, which behavior and personality change would the nurse teach coping strategies for? Select all that apply. A) Paranoia B) Mood stability C) Hallucinations D) Aggressiveness E) Improved decision making

A, C, D Alzheimer disease affects older adults, and the disease may cause chronic confusion. In patients with Alzheimer disease, paranoia (suspicious behavior) is common. Hallucinations may occur because of confusion. Aggressiveness may also increase as part of behavioral changes that occur in Alzheimer disease. The patient may experience rapid mood swings and be unable to make decisions because of the confusion.

Which caregiver's statement indicates understanding of the nurse's teachings about the necessary steps to manage the patient's Alzheimer disease (AD)? Select all that apply. A) "I should install smoke alarms." B) "I should take my mom to parties." C) "I should allow my mom to be independent." D) "I should provide lights in all the rooms." E) "I should feed her whenever she is hungry."

A, C, D Caregivers should not take patients with AD to parties or large social gatherings because the environment is likely to make them feel uncomfortable. A predictable routine for eating meals should be established and followed. The caregiver should install smoke alarms, fire alarms, and natural gas detectors in the home for safety purposes and maintain lighting in all the rooms to prevent fear and help with orientation. The caregiver should allow the patient to be as independent as possible to help maintain self-respect.

What side effects should the nurse monitor for when caring for a patient prescribed donepezil (Aricept)? SATA A) Insomnia B) Constipation C) Bradycardia D) Dizziness E) Headache

A, C, D, E

The nurse assesses a client with a diagnosis of early-stage Alzheimer's disease. Which assessment findings would the nurse expect for this client? Select all that apply. A) Forgetfulness B) Hallucinations C) Wandering D) Urinary incontinence E) Difficulty eating F) Personality changes

A, E

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement INITIALLY? A) Move the client next to the nurses station B) Use an indirect light source and turn off the TV C) Keep the TV and a soft light on during the night D) Play soft music during the night and maintain a well-lit room

B

A family member of an older adult with delirium who is hospitalized asks why a stuffed animal bear has been placed in the patient's bed. Which explanation does the nurse provide? A) "The bear reminds your loved one, who is suffering from depression, of home and happier times." B) "Your loved one is experiencing delirium, and the bear provides something with which to fidget so the IV tubes aren't pulled out." C) "Older adults often revert to child-like behaviors, including playing with toys such as the bear." D) "The bear is part of your loved one's therapy for feelings of isolation. The patient talks to the bear to provide comfort."

B

A newly admitted male patient has a long history of aggressive behavior toward staff. Which statement by the nurse demonstrates the need for more information about the use of restraint? a. "If his behavior warrants restraints, someone will stay with him the entire time he's restrained." b. "I'll call the primary provider and get an as needed (prn) seclusion/restraint order." c. "If he is restrained, be sure he is offered food and fluids regularly." d. "Remember that physical restraints are our last resort."

B

A nurse is assessing a client recently admitted into a psychiatric unit for observation. Which client behavior is indicative of impaired cognition? A) Mumbling B) Asking repeatedly, "How did I get here?" C) Spending hours staring out the window D) Discussing "the voices" with another client

B

A nurse named Darryl has been hired to work in a psychiatric intensive care unit. He has undergone training on recognizing escalating anger. Which statement indicates that he understands danger signs in regard to aggression? a. "I need to be aware of patients who are withdrawn and sitting alone." b. "An obvious change in behavior is a risk factor for aggression." c. "Patients who seek constant attention are more likely to be violent." d. "Patients who talk to themselves are the most dangerous."

B

An appropriate expected outcome in individual therapy regarding the perpetrator of abuse would be: a. A decrease in family interaction so that there are fewer opportunities for abuse to occur. b. The perpetrator will recognize destructive patterns of behavior and learn alternate responses. c. The perpetrator will no longer live with the family but have supervised contact while undergoing intensive inpatient therapy. d. A triad of treatment modalities, including medication, counseling, and role-playing opportunities.

B

April, a 10-year-old admitted to inpatient pediatric care, has been getting more and more wound up and is losing self-control in the day room. Time-out does not appear to be an effective tool for April to engage in self-reflection. April's mother admits to putting her in time-out up to 20 times a day. The nurse recognizes that: A) Time-out is an important part of April's baseline discipline. B) Time-out is no longer an effective therapeutic measure. C) April enjoys time-out, and acts out to get some alone time. D) Time-out will need to be replaced with seclusion and restraint.

B

Cognitive-behavioral therapy is going well when a 12 year old patient in therapy reports to the NP: A) I was so mad I wanted to hit my mother B) I thought that everyone at school hated me. That's not true. Most people like me and I have a friend named Todd. C)I forgot that you told me to breathe when I become angry. D) I scream as loud as I can when the train goes by the house

B

Secondary effects of abuse often manifest as arrested development in children due to the fact that: a. Coping is easier than emotional growth b. Energy for development is diverted to coping c. Children cannot differentiate love from abuse d. Abuse fosters a sense of belonging, even if dysfunctional

B

The abused person is often in a dependent position, relying on the abuser for basic needs. At particular risk are children and the elderly due to: a. The love they have for parents or children. b. Their limited options. c. The need to feel safe at home. d. Other relatives do not want them

B

The nurse in the ED is caring for a victim of sexual assault. The client's physical assessment is complete, and evidence has been collected. The nurse notes that the client is withdrawn, distracted, tremulous, and bewildered at times. How should the nurse interpret these behaviors? A) Signs of depression B) Reactions to a devastating event C) Evidence that the client is a high suicide risk D) Indicative of the need for hospital admission

B

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event? A) Witnessing a murder B) The death of a loved one C) A fire that destroyed the clients home D) A recent rape episode experienced by the client

B

What situation associated with a caregiver presents the greatest risk that an older adult will experience abuse by that caregiver? a. The caregiver is a single male relative. b. The caregiver was neglected as a child. c. The caregiver is under the age of 30. d. The caregiver has little experience with the elderly.

B

When considering the pathophysiology responsible for both delirium and dementia, which intervention is appropriate for delirium specifically? A) Assist with needs related to nutrition, elimination, hydration, and personal hygiene B) monitor neurological status on an ongoing basis C) place ID bracelet on patient D) give one simple direction at a time in a respectful tone of voice

B

Which statement made by a sexually assaulted patient strongly suggests the drug gamma-hydroxybutyrate acid (GHB) was involved in the attack? a. "I remember everything that happened, but felt too tired to fight back." b. "The drink I was given had a salty taste to it." c. "They tell me I was unconscious for 24 hours." d. "I heard that I was fighting the nursing staff and saying that they were trying to kill me."

B

Which is the emergency department nurse's priority action when caring for a patient with head, neck, and facial trauma resulting from domestic violence? A) Assessing the patient's neurologic status B) Protecting the cervical spine when positioning the patient C) Assessing the patient's heart rate and blood pressure D) Checking for the presence or absence of peripheral and central pulses

B A domestic violence victim with head, neck, and facial trauma may have a spinal cord injury, so the emergency department nurse should protect the cervical spine by aligning the neck manually and by using a jaw-thrust maneuver when establishing an airway. After protecting the cervical spine, the emergency department nurse can then assess the patient's neurologic status, check the heart rate and blood pressure, and check for the presence or absence of peripheral and central pulses.

What is the best nursing action when preparing to discharge a patient who denies domestic violence even though it is suspected? A) Call the police. B) Consult with Social Services. C) Discharge the patient as instructed. D) Instruct the patient to go to a safe place.

B If discharge home is not deemed safe, consulting with a social worker or case manager will assist with investigating resource needs and developing a plan, and the patient may be admitted to the hospital until resources can be organized to provide a safe environment. Social workers or case managers are consulted to investigate resource needs and plan accordingly. Calling the police is not an appropriate response. Letting the patient go home could place the patient in danger. The patient may not have a safe place to go.

Which problem does the nurse identify when an older adult reports being hit by a family caregiver when the patient does not keep the house tidy? A) Elder neglect B) Physical abuse C) Financial abuse D) Emotional abuse

B Neglect and abuse can be a problem for some vulnerable older adults. Hitting, burning, pushing, and molesting a patient are examples of physical abuse. The use of physical force may result in bodily injury. When the caregiver fails to provide for the basic needs of the older adult such as food, clothing, and medications, it is considered elder neglect. Financial abuse occurs when there is improper or illegal use of the older adult's funds, property, or assets. Emotional abuse occurs when somebody inflicts mental pain, anguish, or distress on another person through use of threats, intimidation, humiliation, and isolation.

Who does the nurse contact when physical abuse or neglect is suspected in a hospitalized older adult? A) The patient's family B) The hospital social worker C) Local advocacy organization D) The local Adult Protective Services agency

B The nurse working in a hospital or nursing home should notify the hospital social worker when abuse or neglect is suspected. Notifying the family does not fulfill the nurse's responsibility for reporting, and the family may be involved in the abuse or neglect. A nurse working in the community should notify the local advocacy organization or Adult Protective Services agency.

Which nursing action is appropriate when caring for a patient who is the victim of domestic violence and is afraid to return to his or her partner? A) Tell the victim to leave the partner as these things rarely improve. B) Develop a safety plan that will help the victim escape the violent relationship. C) Request that the victim to contact the nearby police station so that the abusive partner can get arrested. D) Inform the victim to contact the psychiatric crisis nurse team to get his or her partner appropriate treatment

B When caring for a patient who is a victim of domestic violence and is afraid to return to his or her partner, it is appropriate to develop a safety plan to facilitate the victim's escape because a victim is most at risk for being killed when he or she decides to leave

The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior exhibited by the client is escalating. Which nursing intervention is most helpful to this client at this time? SATA A) Initiate confinement measures B) Acknowledge the client's behaviors C) Assist the client to an area that is quiet D) Maintain a safe distance from the client E) Allow the client to take control of the situation

B, C, D

A new case management nurse has been hired at a nursing home to investigate several recent resident deaths at the facility. What factors should the case management nurse assess for at the facility? (Select all that apply.) A) High ratio of overweight residents B) Unexplained bruising of residents C) Altered cognitive function of residents D) Skin breakdown in residents resulting from poor hygiene E) Documentation of prescribed physical therapy sessions

B, C, D In addition to psychological signs such as depression, signs of elder abuse include bruising from physical abuse and skin breakdown from neglect of hygiene and nutrition; frailty and decreased cognitive function are also risk factors for abuse. Overweight residents and following prescribed treatments are not indicators of abuse or neglect.

Which assessment tool can be used to evaluate a patient for delirium? Select all that apply. A) Braden Scale B) Delirium Index (DI) C) Neelon and Champagne (NEECHAM) Confusion Scale D) Confusion Assessment Method (CAM) E) Elder Assessment Instrument (EAI)

B, C, D The various assessment tools available to evaluate a patient for delirium include the NEECHAM Confusion Scale, CAM, and DI, as well as the Mini-Cog. The NEECHAM measures the level of confusion in cognitive processing, behavior, and physiologic control. The CAM consists of nine questions and a diagnostic algorithm for determining delirium. The DI is adapted from the CAM and serves as a measure of severity of delirium based on patient observation. The Braden Scale is an assessment tool to evaluate the risk for pressure ulcers in older adults. The EAI is a tool to screen for elder abuse and neglect and is used by nurses and health care professionals.

Which instruction would the nurse provide to family members of a patient with Alzheimer disease? Select all that apply. A) Avoid keeping any familiar items in the room. B) Reminisce about pleasant experiences from the past. C) Keep environmental distractions and noise to a minimum. D) Avoid pictures of family and close friends labeled with names. E) Remove or cover any abstract painting or wallpaper if the patient becomes frightened.

B, C, E In Alzheimer disease, the family members of the patient should reminisce about pleasant experiences from the past to improve the patient's memory and help in recall. Caregivers should minimize environmental distracters and noises to reduce disturbance to the patient. If the patient becomes frightened when seeing any abstract painting or wallpaper, the family members should remove or cover it to reduce patient's fear. The family members should keep familiar items in the patient's room to help the patient's memory. Show pictures of family members and close friends with names to help the patient's memory.

Which finding does the nurse identify as an indication of neglect in older adults? Select all that apply. A) Seizures B) Urine burns C) Dehydration D) Hypertension E) Pressure ulcers

B, C, E Urine burns result from skin that has been in contact with urine for long periods of time; for example, when a patient is incontinent and not provided with hygiene care for hours. Dehydration occurs when a patient is not assisted or reminded to take in fluids. Pressure ulcers can occur when immobile patients are not turned and positioned frequently. Seizures and hypertension are not associated with neglect.

A client says to the nurse, "The federal guards were sent to kill me." Which is the BEST response by the nurse to the client's concern? A) I don't believe this is true B) The guards are not out to kill you C) Do you feel afraid that people are trying to hurt you? D) What makes you think the guards were sent to hurt you?

C

A client with moderate dementia asks the nurse to find her son who is deceased. What is the nurse's most appropriate response? A) "We can call him in a little while if you want." B) "Your son died over 20 years ago." C) "What did your son look like?" D) "I'll ask your husband to find him when he visits."

C

A cognitively impaired nursing home resident is beginning to show physical signs of agitation. Which activity would be most therapeutic to de-escalate the client's agitation? A) Playing bingo with the other residents B) Spending time alone in the client's room C) Taking a walk outside with the nurse D) Watching TV in the presence of staff

C

A nurse is caring for a client who states, " Lately I'm getting forgetful about things. I'm so afraid I'm getting Alzheimer's disease." Which response by the nurse is most therapeutic? A) Now, I don't think we really need to discuss this. I'm sure it is just normal aging B) I'm forgetful too. I have to make lists to remember everything C) Although it's not unusual to experience some lapses of memory, let's discuss your concerns D) Oh, what you are describing isn't Alzheimer's disease. It's much more complicated that that

C

An effective method of preventing escalation in an environment with violent offenders is to develop a level of trust through: a. A casual authoritative demeanor b. Keeping patients busy c. Brief, frequent, nonthreatening encounters d. Threats of seclusion or punishment

C

CPS has removed 10 year old Christopher from his parents' home due to neglect. Christopher reveals to the nurse that he considers the woman next door his "nice" mom, that he loves school, and gets above average grades. The strongest explanation of this response is: A) temperament B) genetic factors C) resilience D) paradoxical effects of neglect

C

John Patrick is a widower with four daughters. He has enjoyed a healthy relationship with all of them until they reached puberty. As each girl began to mature physically, he acted in an aggressive manner, beating her without provocation. John Patrick is most likely acting on: a. Self-protective measures b. Stress of raising four daughters c. Frustration of unhealthy desire d. Motivating his daughters to be chaste

C

Nancy is a nurse. After talking with her mother, she became concerned enough to drive over and check on her. Her mother's appearance is disheveled, words are nonsensical, smells strongly of urine, and there is a stain on her dressing gown. Nancy recognizes that her mother's condition is likely temporary due to: A) Early onset dementia B) A mild cognitive disorder C) A urinary tract infection D) Skipping breakfast

C

The adult children of an older patient seek help from the nurse about how to manage the parent's new onset of delirium. Which statement made by the nurse offers an accurate and therapeutic response? A) "Confusion is a normal part of the aging process. I'll share some techniques for helping manage your parent's behavior." B) "Your parent's delirium is most likely caused by a tumor. Brain scans will be prescribed to check the progression of the condition." C) "There are many factors that can cause delirium. Let's discuss any major changes in your parent's life and evaluate the medications being taken." D) "Delirium is a progressive disorder that cannot be reversed. Your parent will require constant supervision because the confusion poses a safety risk."

C

The novice nurse is learning how to manage delirium in the patient population at an assisted living facility. Which statement made by the nurse indicates the need for further education? A) "Playing soothing music may help calm a resident who has become agitated." B) I should not feel silly reminding the resident where he or she is a few times an hour." C) "At the onset of restlessness, I should put the resident in soft restraints to prevent injury." D) I can ask the resident's family for a favorite item to distract the resident from interfering with equipment."

C

The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway and making aggressive and belligerent gestures at the other clients. Which statement would be most appropriate to make to this client? A) You need to stop that behavior now B) You will need to be placed in seclusion C) You seem restless; tell me what is happening D) You will need to be restrained if you do not charge your behavior

C

Which statement made by the primary caregiver of a patient diagnosed with dementia demonstrates accurate understanding of providing the patient with a safe environment? A) the local police know that he has wandered off before B) I keep the noise level low in the house C) We've installed locks on all the outside doors D) our telephone number is always attached to the inside of his shirt pocket

C

Which finding places the resident of a nursing home at risk for delirium? A) 60-year history of type 1 diabetes B) Two falls in the past week C) Death of the spouse in the past month D) Multiple fractures in the past 2 month

C Experiencing a major loss like the death of a spouse is a factor that can cause delirium, so this will alert the nurse that the patient may be at risk. Type 1 diabetes is not relevant to delirium. A recent history of falls is a risk factor for subsequent falls, not delirium. Having suffered multiple fractures in a short period of time may be an indicator of abuse, not delirium.

Which factor has not been shown to increase the risk for violence in the lesbian, gay, bisexual, transgender, and questioning (LGBTQ) population? A) Poverty B) Sex work C) Education D) Homelesness

C Poverty, sex work, and homelessness are all factors that increase the risk for violence among the LGBTQ population. Education is not a factor that is linked to violence in this population.

A female patient arrives at the emergency department visibly upset and tearful. She refuses to have a male caregiver, asks for a room close to an exit door, and does not make eye contact with staff. What does the nurse suspect is happening with the patient? A) The patient may be having an acute psychotic episode related to her mental illness. B) The patient may be abusing street drugs and needs a drug screening test. C) The patient may have been the victim of an acute assault. D) The patient may be a very demanding and particular person.

C Refusing care from a caregiver of another gender, wanting easy escape access, and having poor eye contact all indicate that an assault may have occurred. Acute psychosis, use of street drugs, or being a demanding person does not elicit the signs of wanting to protect herself from others

Which characteristic would the nurse associate with the Alzheimer Association's Safe Return Program? A) The program receives funds from well-known private organizations. B) The association's program assists families of patients with dementia, worldwide. C) The group assists in identifying patients and returning them safely to their family. D) The program provides information through seminars and publications to nurses and health care workers.

C The Alzheimer Association's Safe Return Program consists of a 24-hour hotline that assists in identifying dementia patients and returning them safely to their families. It is for families of dementia patients in the United States and is a national program funded by the U.S. government. It provides information to dementia patients and their families, not nurses and health care workers, by arranging seminars and publications.

For patients with dementia, which prescribed medication would the nurse administer to treat those patients who also experience hallucinations? A) Donepezil B) Paroxetine C) Haloperidol D) Amitriptyline

C The health care provider may prescribe haloperidol, an antipsychotic medication, for older-adult patients diagnosed with dementia and also experiencing hallucinations. Donepezil is a drug potentially used to treat dementia, but not hallucinations. Paroxetine and amitriptyline are antidepressants, which are not effective for treating hallucinations.

Which condition manifests as delirium in patients on mechanical ventilation? A) ICU paranoia B) ICU dementia C) ICU psychosis D) ICU depression

C The use of mechanical ventilation for a patient in the ICU can cause anxiety and delirium, a condition known as "ICU psychosis." Paranoia involves a patient being overly suspicious, not delirious. Dementia may manifest as delirium, but it is the result of cognitive disorders and aging, not anxiety. Depression may occur in a patient on mechanical ventilation in the ICU, but it is not characterized by delirium.

A nurse is presenting a workshop on interpersonal violence prevention. Which is a common risk factor for interpersonal violence should be addressed in the workshop? A) Poor working conditions B) Hypertension medications C) Alcohol use D) Poor self-esteem

C The use or misuse of alcohol is a risk factor in partner violence, child abuse, youth abuse, and elder abuse. Poor working conditions add to stress but would not be a risk factor that most abuse incidents have in common. Hypertension medications do not increase the risk of abusive episodes. Poor self-esteem is not a common risk factor for most abusive episodes.

Darnell is a 84 year-old widower who has lived alone since his wife died 6 years ago. A neighbor called Darnell's son to tell him that Darnell was trying to start his car from the passenger side. He became angry and aggressive when the car would not start. After a medical assessment, Darnell was diagnosed with a major neurocognitive disorder. The nurse realized additional family teaching is necessary when Darnell's son states: A) My father's diagnosis is interfering with his daily functioning B) This neurocognitive disorder will probably progress C) Advancing age is a risk factor in my father's diagnoses D) With person-centered care, my father will be able to remain in his home

D

Ophelia, a 69-year-old retired nurse, attends a reunion of her former coworkers. Ophelia is concerned because she usually knows everyone, and she cannot recognize faces today. A registered nurse colleague recognizes Ophelia's distress and "introduces" Ophelia to those attending. The nurse practitioner recognizes that Ophelia seems to have a deficit in: A) Lower-level cognitive domain B) Delirium threshold C) Executive function D) Social cognition

D

The nurse is caring for a client who is diagnosed with early-stage Alzheimer's disease who has periods of lucidity. What is the best principle for the nurse to use when communicating with this client? A. Use validation therapy to prevent upsetting the client. B. Encourage pet therapy to help allay the client's anxiety. C. Use aromatherapy and other integrative therapies to relax the client. D. Reorient the client frequently to foster reality.

D

What safety-related responsibility does the nurse have in any situation of suspected of abuse? a. Protect the patient from future abuse by the abuser. b. Inform the suspected abuser that the authorities have been notified. c. Arrange for counseling for all involved parties but especially the patient. d. Report suspected abuse to the proper authorities.

D

When providing care for a patient in the last stage of Alzheimer disease, which strategy would the nurse implement to promote communication? A) Ask indirect questions. B) Use ambiguous gestures. C) Assume the patient is confused. D) Provide instruction with pictures.

D

Which comorbid condition would result in cautious use of a selective serotonin reuptake inhibitors for a patient with chronic aggression? a. Asthma b. Anxiety disorder c. Glaucoma d. Bipolar disorder

D

Which statement about dementia in older adults is correct? A) Dementia is also referred to as acute confusion. B) Dementia is often reversible within a month or so. C) It is most commonly seen as multi-infarct dementia. D) It represents a global impairment of cognitive function.

D

Which information would the nurse relay to a stressed caregiver who provides care for an older-adult family member with Alzheimer disease? A) "Respite care should be used very sparingly." B0 "You should spend time away resting once a month." C) "Do not try to use humor with an Alzheimer patient." D) "Consider attending local support group meetings conducted by the Alzheimer's Association."

D Attending the local support group meetings conducted by the Alzheimer's Association can help reduce the caregiver's stress. The nurse should ask the caregiver to spend time away from the patient every day to rest, not just once a month. The nurse should encourage the caregiver to use respite care when available. Using humor with the Alzheimer patient may also be beneficial for reducing stress.

Which patient assessment finding from the Confusion Assessment Method (CAM) is most indicative of delirium? A) Inability to remember information that is discussed; low oxygen saturation level; hyperalert B) Sudden change in the baseline mental status; incoherent thinking and conversation; lethargy C) Sudden onset of difficulty focusing attention; lethargy; agitation when not permitted to get out of bed D) Sudden change in the baseline mental status; difficulty remembering information that is discussed; disorganized thinking

D Diagnosis of delirium using the CAM depends on four features: The first is acute onset and fluctuating course, the second is inattention, the third is disorganized thinking, and the fourth is an altered level of consciousness. Diagnosis requires the presence of the first and second features along with either the third or fourth feature. The assessment of the patient whose mental status has suddenly changed from the baseline, who is unable to remember information that is discussed, and whose thinking has become disorganized shows the presence of the first, second, and third features. The other assessment findings do not exhibit the correct combination of these features or exhibit additional features not assessed by the CAM

Which type of assessment is the nurse performing when listening to family members discuss feelings of guilt and anger over a patient's traumatic brain injury? A) Imaging B) Physical C) Laboratory D) Psychosocial

D Discussing family members' feelings and coping strategies is a part of a psychosocial assessment. Examining the patient's appearance and reflexes are examples of parts of the physical assessment. Blood tests encompass the laboratory assessment. Imaging techniques like CT and MRI comprise the imaging assessment.

The nurse is assessing a 4-year-old child in a health clinic. Which situation should cause the nurse to explore for possible abuse? A) Being brought to the clinic from daycare B) Recent scrapes and bruises on both knees C) The caregiver reporting angry outbursts from the child while they were in a store D) Different explanations of the injury from the child's parents

D Inconsistent explanations from parents for how injuries occurred is a cause for further investigation. Being brought in from daycare, school, camp, or other public areas does not automatically indicate abuse. Scrapes on the knees are a common developmental injury for a 4 year old. Angry outbursts or tantrums in children in this age-group are still expected developmental behaviors.

Which diagnostic test will be beneficial to assess a patient who is suffering from dementia and metabolic disorders? A) Cerebral angiography B) CT C) MRI D) Positron emission tomography (PET)

D PET is an advanced technique and is most useful in determining the function of the brain, specifically glucose and oxygen metabolism, and cerebral blood flow. This test also detects metabolic abnormalities associated with dementia or other diseases. Cerebral angiography and a CT scan are not helpful in determining brain function. An MRI can also be used, but is not as efficient as a PET scan.

The nurse is reviewing the needs of a patient with cognitive impairment. What is the priority concern the nurse should address? A) Promoting at least 6 hours of sleep a night B) Encouraging an oral intake of 1200 calories per day C) Managing the patient's pain from arthritis D) Supervising medication administration

D Safety is the priority concern for the cognitively impaired patient; safely taking medication addresses safety needs for the patient. Sleep, nutrition, and management of pain are important components of the patient's care and can affect overall health, but safety is the highest priority.

Which condition does the nurse anticipate in a patient with mild dementia with impaired physical function and lack of self-management? A) Hypoxia B) Hypertension C) Gastroenteritis D) Sleep deprivation

D Sleep deprivation at any age may cause cognition changes because sleep is important for health. Sleep deprivation causes impaired physical function and impaired self-management and worsening symptoms of mild dementia. Hypoxia causes changes in mental status. Hypertension often goes undetected and does not impair physical function and self-management. Gastroenteritis does not worsen mild dementia.

Which response would the nurse make when a friend expresses fears regarding his or her mother becoming older, extremely forgetful and disoriented, and beginning to wander? A) "I bet she has Alzheimer disease." B) "Those behaviors are a normal part of aging." C) "You should look into obtaining respite care." D) "Have you taken her for a checkup recently?"

D The mother's symptoms indicate possible Alzheimer disease or some other physiologic imbalance and need further assessment by a health care provider. The nurse cannot diagnose Alzheimer disease. The mother's behavior is not normal age-related behavior. Respite care is for caregivers, not for patients. The friend did not express personal exhaustion that would suggest a need for respite care.

The nurse is establishing a therapeutic environment for a patient admitted with dementia and influenza. Which intervention would be important for the nurse to implement? A) Keep a radio on all the time to provide sound for the patient. B) Decrease patient confusion by limiting verbal interactions. C) Limit family visits to one person for 30 minutes per day. D) Provide a quiet environment in a private room

D The patient experiencing dementia needs a quiet environment with a minimum of unfamiliar stimulation from a roommate. A patient with dementia does not need extra stimulation from having a radio on continually. The nurse should speak clearly and quietly to the patient before any procedure or assistance to decrease agitation. Family visits would be encouraged because family members are familiar to the patient and their presence increases a sense of security.

When the spouse of a patient with dementia states, "I am so tired and worn out," which response would the home health nurse use? A) Can't you take care of your spouse by yourself?" B) "That's not a very nice thing to say about your spouse." C) "Establishing goals and a daily plan can help with the required care." D) "Make sure you take time off to take care of yourself. Is there anyone else to help?"

D The response to take personal time is supportive and reminds the spouse/caregiver that he or she cannot provide care for the patient when exhausted. Of course, further assessment and planning will be necessary. Questioning the spouse's ability to provide care is not supportive and may offend the spouse. Establishing goals and a daily plan is not a helpful response. A better response would be, "Take one day at a time." Suggesting that the spouse's comment was not nice is judgmental and inappropriate.

Which role does the forensic nurse have when caring for a patient who is a victim of intimate partner violence and requires admission to a psychiatric facility? A) Improving quality of care B) Facilitating a follow-up treatment plan C) Admitting the patient to a psychiatric facility D) Encouraging the patient to develop a safety plan of escape

D The role of the forensic nurse in cases of intimate partner violence is to encourage the patient to get away from the violent relationship. Improving the quality of care, facilitating a follow-up regimen, and admitting the patient to a psychiatric facility is the role of the psychiatric crisis nursing team.

Which statement about delirium in older adults is correct? A) "The onset of delirium is usually slow." B) "Surgery and infection can cause delirium." C) "Reorientation is not an effective nursing intervention." D) "Management is based solely on symptomatic treatment."

B

Which statement is an accurate depiction of sexual assault? a. Rape is a sexual act. b. Most rapes occur in the home. c. Rape is usually an impulsive act. d. Women are usually raped by strangers.

B

Which statement made by a new mother should be explored further by the nurse? a. "I have three children, that's enough." b. "I think the baby cries just to make me angry." c. "I wish my husband could help more with the baby." d. "Babies are a blessing, but they are a lot of work."

B

For the patient with Alzheimer disease (AD), which aspect would the nurse include with the primary focus of identifying abnormalities in cognition? Select all that apply. A) Posture B) Behavior C) Language D) Alertness E) Personality

B, C, E The primary focus for nursing assessment of a patient with AD is to identify abnormalities in cognition, including behavior, language, and personality. Posture and alertness are not included in the initial assessment of a patient with AD.

Which assessment includes mobility, sensation, and cognition as parameters? A) Skin assessment B) Urinary assessment C) Neurologic assessment D) Perceptual assessment

C

Which nursing intervention will the nurse implement for a patient exhibiting symptoms of dementia whose condition is deteriorating? Select all that apply. A) Recommending physical exercise B) Instructing the patient to follow a nutritious diet C) Ensuring the patient's bedroom is quiet at night D) Employing memory aids such as using alarms and notes E) Helping the patient stay on a regular sleep schedule

C, E

Chronic obstructive pulmonary disease, spinal injury, seizure disorder, and pregnancy are conditions that: a. Frequently result in out of control behavior. b. Respond well to therapeutic holding. c. Necessitate the use of only two-point restraint. d. Contraindicate restraint and seclusion

D

Considering the guilt that women feel after being sexually assaulted, which nursing assessment question has priority? a. "Do you want the police to be called?" b. "Did you recognize the person who assaulted you?" c. "Do you have someone you trust that can stay with you?" d. "Do you have any thoughts about harming yourself?"

D

Which activity is most appropriate for a child with ADHD? A) Reading an adventure novel B) monopoly C) checkers D) tennis

D