Alzheimer's disease & Delirium

1) An older adult client complains of periods of confusion and forgetfulness, but reports clear thought process at most times of the day. Which is the appropriate response from the nurse? A) "Are you having trouble hearing?" B) "You probably have nothing to worry about. It's most likely stress-related." C) "Everybody has a few problems with memory as they get older." D) "You should probably have an MRI of your brain."

A) "Are you having trouble hearing?"

19) The nurse is teaching the family of a client who has just been diagnosed with dementia. The family asks if there are treatments available that will cure the client. What would be the nurse's best response to the family? A) "There are no treatments that will cure dementia at this time." B) "Treatments to cure dementia include the use of vitamin E." C) "Treatments to cure dementia involve hormone replacement therapy." D) "There are no treatments that can slow the progression of the disease."

A) "There are no treatments that will cure dementia at this time."

5) An older adult client, hospitalized post-surgery, wakes up in the middle of the night very confused. The nurse reorients the client to the surroundings and gets the client to return to sleep. Which should the nurse consider as a source for the client's confusion? A) Ambien (zolpidem), a hypnotic/sedative, taken at bedtime for sleep B) The client's age C) The death of the client's husband last month D) History of cardiac disease

A) Ambien (zolpidem), a hypnotic/sedative, taken at bedtime for sleep

4) A nurse is preparing an educational program for clients in a long-term care facility regarding protective factors for Alzheimer disease (AD). Which information should the nurse include? Select all that apply. A) Becoming involved in activities such as reading that keep the mind active B) Incorporate a high-calorie, high-carbohydrate diet to decrease formation of amyloid plaques C) Remain socially active D) Including modest exercise into daily regimen E) Begin drinking a glass of wine each night before bed

A) Becoming involved in activities such as reading that keep the mind active C) Remain socially active D) Including modest exercise into daily regimen

13) A home health nurse visits a client with stage 2 Alzheimer disease who lives at home with a spouse. Which action by the nurse enhances the spouse's ability to meet the needs of the client? A) Encouraging the caregiver to obtain rest and eat a healthy diet B) Providing the client a list of daily activities to complete C) Making arrangements for the client to visit the local senior citizen center in the afternoon D) Finding placement in a long-term care facility

A) Encouraging the caregiver to obtain rest and eat a healthy diet

2) An adult child brings a parent in to be evaluated and is told the client has Alzheimer disease. The adult child asks the nurse if he is also at risk for the disease. Which risk factors should the nurse include when responding? Select all that apply. A) Genetic predisposition B) Age C) History of hypertension D) Hearing deficits E) Gender

A) Genetic predisposition B) Age C) History of hypertension E) Gender

5) The nurse is planning care for a client with stage 1 Alzheimer disease. Which are the priority nursing diagnoses for the client and family? A) Impaired Memory and Caregiver Role Strain B) Hopelessness and Functional Family Processes C) Knowledge Deficit and Ineffective Coping D) Pseudohostility and Ineffective Coping

A) Impaired Memory and Caregiver Role Strain

9) A client is diagnosed as having stage 1 Alzheimer disease. Which are appropriate goals for the client and family at this time? Select all that apply. A) Resolving grief over the diagnosis B) Deciding on the desired treatment and selecting a healthcare proxy; sharing the treatment decision with the healthcare proxy C) Beginning cognitive-enhancing medication, such as Aricept D) Setting up a protective physical environment—such as removing throw rugs E) Making provisions for assistance with activities of daily living (ADLs)

A) Resolving grief over the diagnosis B) Deciding on the desired treatment and selecting a healthcare proxy; sharing the treatment decision with the healthcare proxy C) Beginning cognitive-enhancing medication, such as Aricept D) Setting up a protective physical environment—such as removing throw rugs

14) A nurse is caring for a client with Alzheimer disease (AD) who has receptive aphasia. Which area of the brain is likely damaged from AD? A) Temporal lobe B) Limbic system C) Frontal lobe D) Occipital lobe

A) Temporal lobe

10) The nurse identifies a nursing diagnosis of Risk for Injury for a client who is disoriented. Which is an expected outcome for this client's care? A) The client does not sustain injuries during wanderings. B) The client remains continent of bowel and urine. C) The client receives culturally appropriate care. D) The client sleeps through the night and stays awake most of the day.

A) The client does not sustain injuries during wanderings.

13) A nurse manager is educating a group of staff nurses on recognizing the differences between confusion and delirium. Which statements should be included in the teaching? Select all that apply. A) "Delirium is seen only in older adults." B) "Delirium is a reversible condition while dementia is not." C) "Older adults are at higher risk for developing delirium." D) "Younger adult females are at higher risk for developing delirium." E) "Adolescents are more prone to developing delirium than young children."

B) "Delirium is a reversible condition while dementia is not." C) "Older adults are at higher risk for developing delirium."

8) The staff on a care area that has a high percentage of clients with confusion attends an educational program on delirium management. Which statement, made by a staff nurse, indicates that teaching has been effective? A) "It is important to provide education for family members as needed." B) "Sensory deprivation and overstimulation can worsen the symptoms the client exhibits." C) "Decreasing all stimulation in the client's room is essential." D) "The family should involve the client in all conversations and interactions involving care."

B) "Sensory deprivation and overstimulation can worsen the symptoms the client exhibits."

4) The family of an older adult client is informed that the client has delirium. Which statement indicates that the family understands the diagnosis? A) "It's sad that dad is getting dementia." B) "The changes in his behavior came on so quickly, which may be the result of an underlying medical condition." C) "Our father is going to need long-term psychiatric care." D) "Confusion is normal in older adults, and it goes away on its own."

B) "The changes in his behavior came on so quickly, which may be the result of an underlying medical condition."

11) The nurse plans a class about Alzheimer disease for a caregiver support group. Which should the nurse include when teaching this class of caregivers? Select all that apply. A) Glutamatergic inhibitors are the most common class of drugs for treating Alzheimer disease. B) Alzheimer disease accounts for about 80% of all dementias. C) Chronic inflammation of the brain may be a cause of the disease. D) Depression and aggressive behavior are common with the disease. E) Memory difficulties are an early symptom of the disease.

B) Alzheimer disease accounts for about 80% of all dementias. C) Chronic inflammation of the brain may be a cause of the disease. D) Depression and aggressive behavior are common with the disease. E) Memory difficulties are an early symptom of the disease.

6) The nurse is planning care to address safety needs for an older adult client who has recently been diagnosed with early Alzheimer disease. Which interventions are appropriate to address safety needs? Select all that apply. A) Use of a restraint belt at night to prevent wandering behaviors B) Check shoes for fit and support. C) Contact the department of motor vehicles to have the client's license suspended. D) Keep all familiar objects in the home. E) Remove throw rugs and electrical cords.

B) Check shoes for fit and support. E) Remove throw rugs and electrical cords.

18) A client presents with signs and symptoms of early Alzheimer disease. What would be used to confirm this client's diagnosis? A) Abnormal CT scan findings of plaques and tangles in the brain B) Client history and physical examination C) Positive blood tests for beta-amyloid and tau proteins D) Blood test for amyloid plaques and neurofibrillary tangles

B) Client history and physical examination

11) The nurse is caring for a school-age client who was admitted with pneumonia and high fever. The parents are very upset because the child is now unable to recognize them. Which statements should the nurse include while educating the parents on their child's symptoms? Select all that apply. A) Reorient the client to time and place as much as possible. B) Encourage the family remain at the bedside as much as possible. C) Explain that high fevers can cause delirium. D) Reassure that the confusion will not last very long. E) Teach the family how to care for the child upon discharge.

B) Encourage the family remain at the bedside as much as possible. C) Explain that high fevers can cause delirium.

6) A school-age client is hospitalized with encephalitis and is experiencing delirium. Which intervention promotes a therapeutic environment for this child and family? A) Making sure the parents perform all treatments for their child B) Encouraging the family to remain at the bedside with the client C) Making sure the child comes back for the follow-up appointment D) Providing written instructions before discharge

B) Encouraging the family to remain at the bedside with the client

20) Damage to which region of the brain may result in loss of recent memory? A) Neuron B) Hippocampus C) Cerebrum D) Neurotransmitter

B) Hippocampus

16) A nurse is assessing a client diagnosed with Alzheimer disease (AD) in which the family reports that the client recently lost the ability to live independently and is unable to perform certain activities of daily living (ADLs) such as selecting appropriate clothing or preparing meals. The family's report indicates that the client has progressed to which stage of AD? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4

B) Stage 2

3) The nurse is caring for a client who becomes confused and agitated every evening. Medical reasons for the change in mental status have been ruled out. The nurse correctly communicates to the other healthcare team members that the client is experiencing which phenomenon? A) Delirium B) Sundowning C) Aphasia D) Chronic psychosis

B) Sundowning

9) The nurse is explaining the difference between delirium and dementia to a family member of a client with confusion. Which statement is appropriate for the nurse to include? A) "The cause of delirium is always unknown." B) "Dementia develops suddenly." C) "Delirium is a serious but common occurrence in older adult clients who are hospitalized." D) "Delirium is often confused with depression in older adult clients."

C) "Delirium is a serious but common occurrence in older adult clients who are hospitalized."

12) The nurse is reviewing pharmacologic treatments with a caregiver of an individual with Alzheimer disease. Which statement indicates that teaching has been effective? A) "There are effective drugs, but they cannot be used over a long period." B) "There aren't any drugs that are effective in treating this disease." C) "The earlier the drugs are started, the greater the likelihood they will have benefits." D) "There are drugs that can control symptoms for many years."

C) "The earlier the drugs are started, the greater the likelihood they will have benefits."

10) A client with Alzheimer disease is scheduled to attend occupational therapy three times a week. Which is the purpose of the client attending this type of therapy? A) Improve language deficits B) Improve muscle tone C) Ability to perform activities of daily living D) Improve access to community organizations

C) Ability to perform activities of daily living

7) A hospitalized older adult client suddenly does not recognize an adult daughter and states, "Why hasn't my wife come to see me?" The client's spouse has been deceased for 5 years. Prior to the hospitalization, the client was oriented to person, place, time, and reality. Which nursing diagnoses would be appropriate for this client? Select all that apply. A) Risk for Autonomic Dysreflexia B) Anxiety C) Acute Confusion D) Risk for Injury E) Ineffective Coping

C) Acute Confusion D) Risk for Injury

8) The nurse is educating the family and client, who was recently diagnosed with Alzheimer disease (AD), regarding long-term care placement. Which is the rationale for providing this information to the family at this time? A) It often takes 6 to 12 months for an individual with AD to establish a successful transfer to a facility, and this will allow adequate time. B) It's better to address the issue of placement now instead of later. C) Early introduction to long-term options will allow the client and family time to make a more informed decision. D) Long-term care placement is inevitable with this diagnosis.

C) Early introduction to long-term options will allow the client and family time to make a more informed decision.

7) The nurse is planning care for a client who is experiencing stage 1 Alzheimer disease. Which intervention will best promote cognitive function? A) Ensure there is background music or sound from the television. B) Dim the lights during waking hours. C) Maintain a daily routine. D) Keep social interaction to a minimum.

C) Maintain a daily routine.

2) An older adult client with no history of cognitive impairment is suddenly showing signs of increased confusion and possible delirium. Which health problem should the nurse suspect is causing this client's confusion? A) Cataracts B) Hypertension C) Urinary tract infection D) Lower back strain

C) Urinary tract infection

The spouse of a client with Alzheimer disease does not understand why the client developed the disorder because no one else in the family has the health problem. Which response by the nurse is appropriate? A) "Alzheimer disease develops because of smoking and alcohol intake." B) "Someone in your family must not have been correctly diagnosed with the disorder." C) "Alzheimer disease does not have the same course in every individual." D) "There are genetic and environmental factors in the development of Alzheimer disease."

D) "There are genetic and environmental factors in the development of Alzheimer disease."

17) The nurse is educating a client who is diagnosed with stage 1 Alzheimer disease (AD) and the client's spouse. Which suggestion best promotes maintaining functional ability at this stage? A) Obtain round-the-clock care at home B) Prepare liquid nutrition C) Assist client with ADLs D) Begin making "to-do" lists and use of a calendar

D) Begin making "to-do" lists and use of a calendar

12) Which is true regarding the Confusion Assessment Method (CAM)? A) It consists of five parts and is a lengthy test. B) It measures the severity of the client's delirium. C) It is also effective in screening for depression. D) It is effective in screening for cognitive impairment and reversible confusion.

D) It is effective in screening for cognitive impairment and reversible confusion.

3) A client diagnosed with Alzheimer disease becomes agitated during an activity involving simultaneous music playing and a craft project. The client starts shouting, "No! No! No!" and runs from the room. Which action by the nurse is the most appropriate? A) Administer a prn anti-anxiety medication. B) Restrict participation in any group activities. C) Call security and prepare physical restraints. D) Reassure the client and then redirect to a quiet area.

D) Reassure the client and then redirect to a quiet area.

15) Which is true regarding the pathophysiology and etiology of Alzheimer disease? Select all that apply. A) Damage to the limbic system results in speech decline and slowed movements. B) Familial Alzheimer disease (eFAD) is also called delayed-onset Alzheimer disease. C) Sporadic Alzheimer disease usually manifests before age 65. D) Sporadic Alzheimer disease is more common than familial Alzheimer disease. E) In Alzheimer disease, neuronal cells die in a characteristic order.

D) Sporadic Alzheimer disease is more common than familial Alzheimer disease. E) In Alzheimer disease, neuronal cells die in a characteristic order.