Cognition-HESI
The children of adolescent mothers experience more cognitive developmental problems than children of adult mothers. What could be the possible reasons for this observation? Select all that apply. 1 Adolescent mothers may view the infant as a play thing. 2 Adolescent mothers may be reluctant to seek medical care. 3 Adolescent mothers may lack parental competence. 4 Adolescent mothers are younger than adult mothers. 5 Adolescent mothers usually conceive before they have pelvic adequacy.
1,3
A client on bupropion therapy for depression experiences seizures. Which actions of the primary healthcare provider are used to reduce the risk for seizures? Select all that apply. 1 Discouraging rapid dose titration 2 Maintaining the dose at 550 mg/day 3 Avoiding administration of the medication with paroxetine 4 Avoiding concomitant use of fluoxetine with the medication 5 Administering the medication with small doses of fluoxetine
1,3,4
During a home visit to an older adult, the nurse observes a change in behavior and suspects delirium. The nurse assesses the client for one of several conditions that may have precipitated the delirium. Select all that apply. 1 Infection 2 Dementia 3 Dehydration 4 Urine retention 5 Restricted mobility
1,3,4
What important step should the community nurse take when dealing with older adults with a confusional states problem? Select all that apply. 1 The nurse should provide a protective environment. 2 The nurse should monitor blood pressure and weight. 3 The nurse should recommend applicable community resources. 4 The nurse should demonstrate proper hygiene to the primary caretaker. 5 The nurse should educate about polypharmacy and drug-drug and drug-food interactions
1,3,4
A nurse is assessing a client with dementia. Which clinical manifestations are expected? Select all that apply. 1 Agitation 2 Pessimism 3 Short attention span 4 Disordered reasoning 5 Impaired motor activities
1,3,4,5
An older client is diagnosed with Alzheimer disease. For which clinical manifestations should the nurse assess the client? Select all that apply. 1 Loss of recent memory 2 Focused attention span 3 Perceptual disturbances 4 Willingness to accept change 5 Difficulty learning something new
1,3,5
While assessing an elderly client, a nurse infers cognitive impairment. Which statements made by the client confirm the nurse's conclusion? Select all that apply. 1 "I have difficulty judging things." 2 "I forget to take medicines." 3 "I am unable to do financial calculations." 4 "I get confused about the proper date and time." 5 "I am unable to recall words during conversations with my family."
1,3,5
The student nurse is learning about the developmental characteristics of vision. Which major developmental characteristics does an infant start exhibiting around age 6 weeks? Select all that apply. 1 Having binocular vision 2 Having doll's eye reflex 3 Having visual acuity 20/40 to 20/60 4 Having peripheral vision to 180 degree 5 Having strabismus if binocular vision is absent
1,4
What manifestations does the nurse expect to identify when taking a health history from a client with moderate dementia? Select all that apply. 1 Sundowning 2 Hypervigilance 3 Increased inhibition 4 Exaggeration of premorbid traits 5 Inability to recognize family members
1,4
A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which assessment signs of hepatic encephalopathy should the nurse assess this client? Select all that apply. 1 Mental confusion 2 Increased cholesterol 3 Brown-colored stools 4 Flapping hand tremors 5 Musty, sweet breath odor
1,4,5
A nurse is assessing a client and attempting to distinguish between dementia and delirium. Which factors are unique to delirium? Select all that apply. 1 Slurred speech 2 lability of mood 3 Long-term memory loss 4 Visual or tactile hallucinations 5 Insidious deterioration of cognition 6 A fluctuating level of consciousness
1,4,6
Which of these statements about language development in children ages 12 to 36 months are true? Select all that apply. 1 24-month-old children use pronouns. 2 18-month-old children use approximately 25 words. 3 24-month-old children speak in four-word sentences. 4 24-month-old children have a vocabulary of up to 500 words. 5 36-month-old children learn to use five or six new words each day.
1,5
A 65-year-old retired baker is admitted to the hospital with the diagnosis of dementia. What question by the nurse best tests the client's capacity for abstract thinking? 1 "How are a television and a radio alike?" 2 "Can you give me today's complete date?" 3 "What would you do if you fell and hurt yourself?" 4 "Repeat the following numbers for me: 8, 3, 7, 1, 5."
1
A client arrives at the clinic after being bitten by a raccoon in an area in the woods where rabies is endemic. When considering the client's needs, the nurse recalls that rabies is what? 1 Viral infection characterized by convulsions and difficulty swallowing 2 Parasitic infestation characterized by encephalopathy and opisthotonos 3 Bacterial septicemia resulting in convulsions and a morbid fear of water 4 Catalyst for an autoimmune response that results in a maculopapular rash and fever
1
A client comes to the mental health clinic for treatment of a phobia of large dogs. What should the nurse anticipate that this client will demonstrate? 1 Fear of discussing the phobia 2 Resentment toward the feared object 3 Inadequate impulse control when threatened 4 Distortion of reality when discussing the phobia
1
A client comes to the mental health clinic with the complaint of a progressing inability to be in enclosed spaces. The primary healthcare provider makes the diagnosis of claustrophobia and prescribes desensitization therapy. The nurse recalls that desensitization therapy is used successfully with clients experiencing phobias because it is focused on what technique? 1 Imagery 2 Modeling 3 Role-playing 4 Assertiveness training
1
A client is admitted to the emergency department with head trauma resulting from an accident. The client opens both eyes to painful stimuli, makes incomprehensible sounds, and flexes to pain. Using the Glasgow Coma Scale, which score will the nurse document in the client's medical record? 1 8 2 9 3 12 4 15
1
A client with schizophrenia reports having ongoing auditory hallucinations and describes them as "voices telling me that I'm a bad person" to the nurse. What is the best response by the nurse? 1 "Try to ignore the voices." 2 "What are the voices saying to you?" 3 "Do you believe what the voices are saying?" 4 "They're only voices, so just try not to be afraid."
1
A healthcare provider prescribes oropharyngeal suctioning as needed for a client in a coma. Which assessment made by the nurse indicates the need for suctioning? 1 Gurgling sounds with each breath 2 Fine crackles at the base of the lungs 3 Cyanosis in the nail beds of the fingers 4 Dry cough at increasingly frequent intervals
1
A nurse finds that an older adult has reduced consciousness and fatigue and imagines something that is unreal. Which condition does the nurse suspect in the client? 1 Delirium 2 Dementia 3 Depression 4 Alzheimer's disease
1
A nurse is creating a therapy group for low-functioning clients. Which client is the most appropriate member? 1 A 77-year-old man with anxiety and mild dementia 2 A 52-year-old woman with alcoholism and an antisocial personality 3 A 38-year-old woman whose depression is responding to medication 4 A 28-year-old man with bipolar disorder who is in a hypermanic state
1
A nurse is working in a daycare center with clients who have cognitive impairments. What does the nurse expect of a client in the middle stages of dementia? 1 Ability to recall events from the past 2 Ability to cope effectively with anxiety 3 Ability to follow a simple schedule without help 4 Memory of what was eaten on the previous day
1
According to Erikson, what will happen to an individual who fails to master the maturational crisis of adolescence? 1 Role confusion 2 Interpersonal isolation 3 Rebellion against parental orders 4 Feelings of inferiority on comparing the self to others
1
An older adult resident of a nursing home who has the diagnosis of dementia of the Alzheimer type frequently talks about the good old days at the ranch. What is the most appropriate action by the nurse? 1 Allowing the resident to reminisce about the past and listening with interest 2 Involving the resident in interesting diversional activities with a small group 3 Reminding the resident that those "good old days" are past and that the client should focus on the present 4 Introducing the resident to other residents with the same diagnosis so that they can share their past experiences
1
An older client with a diagnosis of dementia is living in a long-term care facility. The client's daughter, who lives 300 miles (483 km) away, calls the unit to speak to the nurse about her upcoming visit. What should the nurse say in response to her question about the best time of day to visit? 1 "Around 2:30 in the afternoon is the best time to visit." 2 "Whenever is most convenient for you. She'll be glad to see you." 3 "Come at noon. You'll be able to go to the dining room and visit while she eats." 4 "The longest uninterrupted time begins after supper and extends until bedtime, at 8:30 pm."
1
An older client with dementia of the Alzheimer type is residing in a nursing home. When in bed, the client consistently is found sleeping in the semi-Fowler position. What area of the client's body does the nurse determine has the most risk for developing a pressure ulcer? 1 Sacrum 2 Scapulae 3 Ischial spine 4 Greater trochanter
1
An older client with vascular dementia has difficulty following simple directions for selecting clothes to be worn for the day. What does the nurse identify as the cause of these problems? 1 Receptive aphasia 2 Impaired judgment 3 Decreased attention span 4 Clouding of consciousness
1
During a nursing assessment, a nurse notes that a client has begun to create new words. What term does the nurse use to document this finding? 1 Neologism 2 Perseveration 3 Pressured speech 4 Tangential speech
1
The nurse is admitting a confused 80-year-old client to the mental health unit. Which is one factor associated with the aging process? 1 Slowing of responses 2 Changing of personality 3 Lowering of intelligence 4 Diminution of long-term memory
1
The nurse is using Piaget's theory to assess the cognitive development in a child. What is most likely to be the age of the child who has reached a developmental milestone by grasping the concept of conservation of numbers for the first time? 1 5 years 2 7 years 3 9 years 4 12 years
1
What are the "four As" for which nurses should assess clients with suspected Alzheimer disease? 1 Amnesia, apraxia, agnosia, aphasia 2 Avoidance, aloofness, asocial, asexual 3 Autism, loose association, apathy, affect 4 Aggressive, amoral, ambivalent, attractive
1
What characteristic of an environment should the nurse consider important for a confused older adult with socially aggressive behavior? 1 Sets limits 2 Has variety 3 Is group oriented 4 Allows freedom of expression
1
What is the similarity between the stage-crisis theory given by Robert Havinghurst and the psychosocial development theory given by Erikson? 1 Both theories are based on developmental tasks. 2 Both theories incorporate eight stages of development. 3 Both theories are based on changes in a person's thoughts and emotions. 4 Both theories emphasize that a child's growth is directed by individual gene activity
1
Which assessment finding is associated with depression? 1 The client has islands of intact memory. 2 The client has impaired recent and remote memory. 3 The client has impaired recent and immediate memory. 4 The client needs step-by-step instructions for simple tasks.
1
Which period of Piaget's theory describes the idea of object permanence? 1 Sensorimotor period 2 Preoperational period 3 Formal operations period 4 Concrete operations period
1
A student nurse is learning about the social milestones reached by children at different stages of development. Which statement made by the student nurse demonstrates adequate knowledge on the topic? 1 "A 10-year-old child is a boaster." 2 "A 9-year-old child spends a lot of time alone." 3 "An 8-year-old child begins to get interested in boy-girl relationships." 4 "A 6-year-old child plays mostly with groups of the same sex but is beginning to play with children of the opposite sex."
3
An 84-year-old woman is admitted to the hospital with a diagnosis of dementia of the Alzheimer type. What does the nurse know about this disorder? 1 Problem that first emerges in the third decade of life 2 Nonorganic disorder that occurs in the later years of life 3 Cognitive problem that is a slow and relentless deterioration of the mind 4 Disorder that is easily diagnosed through laboratory and psychological tests
3
An adolescent tells the nurse, "I do not go to parties that serve alcohol, not because my dad doesn't like it, but because I know this is not right." What does the statement indicate according to Lawrence Kohlberg's Theory of Moral Development? 1 The statement specifies that the adolescent has reached the 'Social Contract Orientation' stage. 2 The statement specifies that the adolescent has reached the 'Good Boy-Nice Girl Orientation' stage. 3 The statement specifies that the adolescent has reached the 'Society-Maintaining Orientation' stage. 4 The statement specifies that the adolescent has reached the 'Punishment and Obedience Orientation' stage
3
An older client with the diagnosis of dementia, Alzheimer type, is admitted to a nursing home. The client is confused and forgetful, wanders, and has intermittent episodes of urinary incontinence. How should the nurse plan to meet this client's elimination needs? 1 By pointing out the behavior to the client 2 By obtaining incontinence pads for the client 3 By taking the client to the bathroom at regular intervals 4 By encouraging the client to call for help when there is an urge to urinate
3
During the first month in a nursing home, a client demonstrates numerous disorganized behaviors related to disorientation and cognitive impairment. What should the nurse's plan of care continue to take into consideration in relation to the client? 1 Level of interest in unit activities 2 Orientation to time, place, and person 3 Ability to perform tasks without becoming frustrated 4 Cognitive impairment, which will increase until adjustment to the home is accomplished
3
During the first month in a nursing home, an older client with dementia demonstrates numerous disruptive behaviors related to disorientation and cognitive impairment. What should the nurse take into consideration when planning care? 1 Client's orientation to time, place, and person 2 Ability to perform daily activities without assistance from others 3 Stressors that appear to precipitate the client's disruptive behavior 4 That cognitive impairments will increase until adjustment to the home is accomplished
3
In her eighth month of pregnancy, a 24-year-old client is brought to the hospital by the police, who were called when she barricaded herself in a ladies' restroom of a restaurant. During admission the client shouts, "Don't come near me! My stomach is filled with bombs, and I'll blow up this place if anyone comes near me." What does the nurse conclude that the client is exhibiting? 1 Ideas of reference 2 Loose associations 3 Delusional thinking 4 Tactile hallucinations
3
The nurse is caring for a client with dementia whose expression of emotions is altered. Which behavior is unexpected with this client? 1 Lability 2 Passivity 3 Curiosity 4 Withdrawal
3
What should the nurse assess first when evaluating memory impairment in a client with dementia? 1 Disorientation of self 2 Recollection of past events 3 Remembrance of recent events 4 Impaired ability to name objects
3
When attempting to assess the behavior of an older adult with a diagnosis of vascular dementia, what does the nurse know is probable about the client's use of defense mechanisms? 1 Incapable of using any defense mechanisms 2 Using one method of defense for every situation 3 Making exaggerated use of old, familiar mechanisms 4 Attempting to develop new defense mechanisms to meet the current situation
3
When working with a client who has a phobia of black cats, what problem does the nurse anticipates for this client? 1 Denying that the phobia exists 2 Anger toward the feared object 3 Anxiety when discussing the phobia 4 Distortion of reality when completing daily routines
3
A nurse is assessing a young adult for evidence of achievement of the age-related developmental stage set forth in Erikson's developmental theory. What developmental crisis is associated with this age group? 1 Trust versus mistrust 2 Intimacy versus isolation 3 Industry versus inferiority 4 Generativity versus stagnation
2
A nurse is working with clients with a variety of eating disorders. Which characteristic unique to bulimia nervosa differentiates this disorder from anorexia nervosa? 1 The client is obese and attempting to lose weight. 2 The client behaves appropriately and looks normal. 3 The client has a distorted body image and sees the body as fat. 4 The client is struggling with a conflict of dependence versus independence.
2
A nursing instructor asks a nursing student about language development in toddlers. Which statement by the student indicates a need for further learning? 1 "A 24-month-old child uses pronouns." 2 "An 18-month-old child uses approximately 25 words." 3 "A 24-month-old child has a vocabulary of up to 300 words." 4 "A 36-month-old child can use simple sentences and follow some grammatical rules."
2
A nursing instructor asks a nursing student to provide information about adolescents. Which statement made by the student indicates the need of further teaching? 1 "Adolescents have risk-taking behaviors." 2 "Adolescents accept their society and its values." 3 "Adolescents consider themselves invincible." 4 "Adolescents think of their parents as materialistic."
2
According to Erikson's theory of psychosocial development, which attribute plays an important role in the development of a healthy personality from birth to 1 year of age? 1 Initiative versus guilt 2 Trust versus mistrust 3 Autonomy versus shame 4 Industry versus inferiority
2
According to Piaget's theory, which period describes a child's stage of egocentrism? 1 Sensorimotor 2 Preoperational 3 Formal operations 4 Concrete operations
2
After assessing a client, the nurse suspects that the client has shift-work sleep disorder (SWSD). Which medication would be prescribed to the client? 1 Caffeine 2 Modafinil 3 Atomoxetine 4 Methylphenidate
2
An older adult client is demonstrating mild confusion after surgical repair of a hernia. What should the nurse do to provide for this client's safety? 1 `Use a nightlight in the client's room. 2 Activate the position-sensitive bed alarm. 3 Raise the four side rails on the client's bed. 4 Secure a prescription for a soft vest restraint.
2
An older adult client with dementia of the Alzheimer type frequently switches from being pleasant and happy to being hostile and unhappy without apparent external cause. How can the nurse best care for this client? 1 By pointing out reality to the client 2 By providing nursing care when the client is receptive 3 By encouraging the client to talk about personal feelings 4 By avoiding caring for the client when hostility is being exhibited
2
An older nursing home resident with the diagnosis of early-onset dementia likes to talk about the old days and at times has a tendency to confabulate. What does the nurse determine is the purpose of the client's confabulation? 1 Prevent regression 2 Increase self-esteem 3 Attract the attention of others 4 Help him reminisce about achievements
2
An older resident in a nursing home who has a diagnosis of dementia hoards leftover food from the meal tray and other seemingly valueless articles and stuffs them into pockets "so the others won't steal them." What should the nurse plan to do? 1 Remove the resident's unsafe and soiled articles during the night. 2 Give the resident a small bag in which to place selected personal articles and food. 3 Explain to the resident why the nursing home's policy for cleanliness and safety must be followed. 4 Explain to the resident that the staff is required to keep harmful objects out of reach in the resident's closet
2
During a peer review, the chief operational officer of a healthcare unit understands that the newly appointed nurse excels in reminiscence theory. What statement of the nurse confirms this understanding? 1 The nurse restores the client's sense of reality. 2 The nurse builds self-esteem by asking about a client's previous achievements. 3 The nurse agrees to a confused client's incorrect statement. 4 The nurse meets the expressed and unexpressed needs of the client
2
The nurse is caring for a 75-year-old client who had radical head and neck surgery. Thirty minutes after awakening from anesthesia, the client becomes agitated, disoriented, and confused. What should the nurse do? 1 Notify the healthcare provider immediately of the findings. 2 Administer the prescribed oxygen. 3 Record the observations and continue to observe the client. 4 Administer the prescribed antianxiety medication
2
The nurse is caring for an 84-year-old man admitted with a diagnosis of severe Alzheimer dementia. In the admission assessment, the nurse notes that the client can no longer recognize familiar objects such as his glasses and toothbrush. What is the best term to describe this situation? 1 Apraxia 2 Agnosia 3 Aphasia 4 Amnesia
2
What is an important nursing assessment for a school-aged child who is undergoing long-term steroid therapy? 1 Monitoring the pulse for irregularities 2 Frequent testing of stools for occult blood 3 Repeated inspections of urine for mucous threads 4 Persistent checking of oral mucous membranes for ulcers
2
What should a nurse include in the plan of care for a client with vascular dementia? 1 Reeducation program 2 Supportive care interventions 3 Introduction of new leisure-time activities 4 Involvement in group therapy sessions
2
What should the nurse include when planning activities for an older nursing home resident with a diagnosis of dementia? 1 Varied activities that will keep the resident occupied 2 Familiar activities that the resident can complete successfully 3 Challenging activities to maintain the resident's contact with reality 4 Ways to ensure that the resident actively participates in the unit's daily activities
2
Which screening report will help the nurse determine skeletal growth in a child? 1 Electroencephalogram reports 2 Radiographs of the hand and wrist 3 Magnetic resonance imaging (MRI) 4 Denver Developmental Screening Test
2
Which stage of Piaget's theory of cognitive development does the nurse observe in a preschooler? 1 Sensorimotor 2 Preoperational 3 Formal operations 4 Concrete operations
2
A 70-year-old retired man has difficulty remembering his daily schedule and finding the right words to express himself. He is found to have dementia of the Alzheimer type. What does the nurse know about symptoms of this disorder? 1 Occur fairly rapidly 2 Have periods of remission 3 Begin after a loss of self-esteem 4 Demonstrate a progression of disintegration
4
A client is admitted to the hospital with a tentative diagnosis of urinary retention related to benign prostatic hyperplasia. The primary healthcare provider notes a secondary diagnosis of delirium related to urosepsis and prescribes the insertion of an indwelling urinary retention catheter. Which nursing action is most important at this time? 1 Secure a prescription for wrist restraints. 2 Orient the client to time, place, and person. 3 Involve family members in the client's care. 4 Determine whether any unsafe behavior patterns exist.
4
A client is admitted with a bipolar disorder, depressed episode. The nursing history indicates a progressive increase in depression over the past month. What should the nurse expect the client to display? 1 Elated affect related to reaction formation 2 Loose associations related to a thought disorder 3 Physical exhaustion related to decreased physical activity 4 Decrease of verbal expression related to slowed thought processes
4
A client with moderate dementia often assaults nursing staff, and the staff members decide to develop a plan to minimize this behavior. What should the plan include? 1 Limiting the time staff and the client spend together 2 An outline of the consequences for uncooperative behavior 3 The client's preferences for use as a reward or a punishment 4 Identification of nursing staff members whom the client prefers
4
A forgetful, disoriented client is exhibiting inappropriate behaviors signifying dementia. Nursing management should be directed toward what goal? 1 Restricting gross motor activity to prevent injury 2 Preventing further deterioration in the client's condition 3 Maintaining scheduled activities through behavior modification 4 Rechanneling the client's energies into more appropriate behaviors
4
A nurse is caring for an older adult with a history of recent memory loss. Which action should the nurse take? 1 Instruct the client to move slowly when changing positions 2 Remind the client to look where places feet while walking 3 Adjust the daily schedule to accommodate sleep pattern 4 Employ electronic devices that provide alerts
4
A nurse is teaching a client and family about the characteristics of dementia of the Alzheimer type. What physiologic characteristic should the nurse include? 1 Periodic exacerbations 2 Aggressive acting-out behavior 3 Hypoxia of selected areas of brain tissue 4 Areas of brain destruction called senile plaques
4
According to Erikson's stages of life, what is the stage when a child begins walking, feeding, and using the toilet? 1 Trust versus mistrust 2 Initiative versus guilt 3 Identity versus role confusion 4 Autonomy versus sense of shame and doubt
4
An older adult is being admitted to a nursing home with the diagnosis of dementia. The history reveals confusion, difficulty recognizing family members, and nighttime wandering. What should the nurse include in the client's plan of care? 1 Ordering a vest restraint for the client to be applied at night 2 Obtaining a prescription for a sedative so the client will sleep better at night 3 Requesting that the family provide a companion to stay with the client at night 4 Assigning the client to a room near the nurses' station for closer supervision at night
4
An older adult with dementia is admitted to a nursing home. The client is confused, agitated, and at times unaware of the presence of others. What is the best nursing approach to help this client adapt to the unit? 1 Initiating a program of planned interaction 2 Explaining the nature and routines of the unit 3 Exploring in depth the reasons for the admission 4 Arranging for the constant presence of a staff member
4
The bed alarm is ringing because an older adult client is attempting to get out of bed. A nurse enters the room and finds the client agitated and confused. The family member is upset and states, "He has never been like this. I don't know what to do." After getting the client back into bed, which nursing action is most appropriate? 1 Asking the family member to step out of the room so the client can rest 2 Placing a vest restraint on the client to prevent the client from falling out of bed 3 Explaining to the family that it is common for older clients to get confused while in the hospital 4 Requesting the nursing assistant to stay with the client while the nurse calls the primary healthcare provider
4
The nurse recognizes that which is the mental process most sensitive to deterioration with aging? 1 Judgment 2 Intelligence 3 Creative thinking 4 Short-term memory
4
The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. What nursing intervention is the priority? 1 Weigh the client daily. 2 Restrict the client's oral fluid intake. 3 Measure the client's urine specific gravity. 4 Observe the client for increasing confusion.
4
What is the priority nursing care for a client with delirium? 1 Providing a body massage 2 Arranging for music therapy 3 Teaching relaxation techniques 4 Creating a calm and safe environment
4
What is the priority nursing objective of the therapeutic psychiatric environment for a confused client? 1 Helping the client relate to others 2 Making the hospital atmosphere more homelike 3 Helping the client become accepted in a controlled setting 4 Maintaining the highest level of safe, independent function
4
While assessing an older adult in the emergency department the nurse notes that the client is upset. The nurse asks what is wrong, and the client describes the current situation and then offers information that goes further and further off the topic. What pattern of communication does this conversation reflect? 1 Perseveration 2 Thought blocking 3 Overcompensation 4 Tangential thinking
4
While caring for a client who was injured in a tornado, the nurse finds that the client is disoriented. Which is the most appropriate nursing intervention to prevent injury in the client? 1 Keeping rails up on the stretcher 2 Keeping the stretcher in lowest position 3 Maintaining adequate lightening in the room 4 Asking a family member to remain with the client
4
While performing the physical assessment of an infant, the nurse notices the infant has developed a color preference for red and yellow. What is most likely to be the age of the infant? 1 4 weeks 2 8 weeks 3 15 weeks 4 20 weeks
4
A nurse communicates with a mother about the cognitive changes that her child will exhibit after becoming an adolescent. Which statements made by the mother indicate adequate learning? Select all that apply. 1 "My child will think in terms of the future." 2 "My child will be able to deal with hypothetical problems." 3 "My child will consider a limited variety of causes and solutions." 4 "My child will be able to imagine multiple outcomes of a situation." 5 "My child will be unable to understand the influence of an individual's ideas on others."
1,2,4
A nurse is assessing an older adult with the diagnosis of dementia. Which manifestations are expected in this client? Select all that apply. 1 Resistance to change 2 Inability to recognize familiar objects 3 Preoccupation with personal appearance 4 Inability to concentrate on new activities or interests 5 Tendency to dwell on the past and ignore the present
1,2,4,5
A client in the early dementia stage of Alzheimer disease is admitted to a long-term care facility. Which activities must the nurse initiate? Select all that apply. 1 Weighing the client once a week 2 Having specialized rehabilitation equipment available 3 Keeping the client in pajamas and robe most of the day 4 Establishing a schedule with periods of rest after activities 5 Reviewing the client's weekly budget and use of community resources 6 Setting up a plan for weekly entertainment through a senior citizens group
1,2,4
The nurse is listing the major developmental characteristics of hearing in infants. Which characteristics appear for the first time at 24 to 32 weeks? Select all that apply. 1 Responding to own name 2 Locating sounds by turning head in a curving arc 3 Locating sound by turning head to side, then looking up or down 4 Locating sound by turning head to side and looking in same direction 5 Localizing sounds by turning head diagonally and directly toward sound
1,2
A nurse is making a home visit to a young client manifesting chronic symptoms of acquired immune deficiency syndrome (AIDS). The nurse assesses the client for what signs of altered mental health function associated with AIDS? Select all that apply. 1 Delusions 2 Memory loss 3 Hopelessness 4 Hyperactivity 5 Paranoid thinking
1,2,3,5
A nurse caring for a client with dementia notes that the primary healthcare provider has prescribed an experimental course of treatment. What important factor should the nurse keep in mind regarding the procurement of informed consent? 1 Clients with mental illness are not allowed to give consent. 2 Clients with mental illness have the right to refuse treatment. 3 Family members of the client need to give consent for all procedures. 4 Primary healthcare providers may perform procedures without consent.
2
A client with dementia is admitted with a fractured hip after a fall at home. The client's family member witnessed the fall. Four hours after admission, the client's blood pressure increases to a moderately severe hypertensive level. The client pulls on the bedclothes continuously. The client's family member asks for pain medication for the client. What does the nurse concludes? 1 The client has the need to go to the bathroom. 2 The client may be in pain and unable to respond appropriately. 3 The family member may be trying to keep the client overmedicated. 4 The family member feels guilty about the fall and wants to keep the client pain free.
2
A 54-year-old has demonstrated increasing forgetfulness, irritability, and antisocial behavior. After the person is found disoriented and semi-naked while walking down a street, the diagnosis of dementia of the Alzheimer type is made. The client expresses fear and anxiety upon admission to a long-term care facility. What is the best nursing intervention in light of the client's diagnosis? 1 Exploring the reasons for the concerns 2 Reassuring the client with the frequent presence of staff members 3 Providing the client with a written schedule of planned interactions 4 Explaining to the client why the admission to the facility is necessary
2
A client experiences a cerebral vascular accident (CVA) and is admitted to the hospital in a coma. What is the priority nursing care for this client? 1 Monitor vital signs. 2 Maintain an open airway. 3 Maintain fluid and electrolytes. 4 Monitor pupil response and equality.
2
A client with a history of atrial fibrillation has a stroke, and vascular dementia (multiinfarct dementia) is diagnosed. In a comparison of assessment findings in clients with vascular dementia and dementia of the Alzheimer type, which factor is unique to vascular dementia? 1 Memory impairment 2 Abrupt onset of symptoms 3 Difficulty making decisions 4 Inability to use words to communicate
2
A client with hepatic cirrhosis begins to develop slurred speech, confusion, drowsiness, and a flapping tremor. Which diet can the nurse expect will be prescribed for this client based upon the assessment? 1 No protein 2 Moderate protein 3 High protein 4 Strict protein restriction
2
The student nurse is performing a rapid baseline assessment using a disability mnemonic (AVPU) in a client with drug abuse. Which parameters should the student nurse consider for proper assessment? Select all that apply. 1 Level of anxiety 2 Reaction to pain 3 Response to voice 4 Body temperature 5 Evidence of assault
2,3
What are the similarities between a preschooler and a school-aged child? Select all that apply. 1 Both have imaginary playmates. 2 Both are curious to know about their surroundings. 3 Both are able to relate the events and their causes. 4 Both understand that one object can exist in two shapes. 5 Both believe that inanimate objects have life-like qualities.
2,3
What developmental skills does a preschooler exhibit? Select all that apply. 1 Personal identity 2 Specific reasoning 3 Increased curiosity 4 Magical thinking 5 Understanding of others
2,3,4
An older client is admitted to the hospital with the diagnosis of dementia of the Alzheimer type and depression. Which signs of depression does the nurse identify? Select all that apply. 1 Loss of memory 2 Increased appetite 3 Neglect of personal hygiene 4 "I don't know" answers to questions 5 "I can't remember" answers to questions
2,3,4,5
What are the different stages of cognitive development in an infant as described by Piaget? Select all that apply. 1 Narcissism 2 Separation 3 Attachment 4 Using symbols 5 Object permanence
2,4,5
A nursing instructor is teaching student nurses about the adaptive behaviors exhibited by children at different stages of development. Which statement made by a student nurse indicates that the student nurse needs further teaching? 1 "A 12-year-old child can write brief stories." 2 "A 7-year-old child can use a table knife for cutting meat." 3 "A 5-year-old child can brush and comb his or her hair acceptably without help." 4 "A 9-year-old child classifies objects by more than one quality and has collections."
3
A 3-year-old child is seen in the emergency department after a fall off a swing, and a possible concussion is diagnosed. When using the Glasgow Coma Scale, what should the nurse remember about most children 3 years of age? 1 They can state their name and address. 2 They will be able to clearly state the time and place. 3 They may not respond to strangers asking questions. 4 They should be assessed without their parents present
3
A client has a diagnosis of schizoid personality disorder. During the assessment what should the nurse expect of the client's behavior? 1 Rigid and controlling 2 Dependent and submissive 3 Detached and socially distant 4 Superstitious and socially anxious
3
A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. When assessing the client, what does the nurse expect to identify? 1 Hypertension 2 Tenacious sputum 3 Altered mental status 4 Slow rate of breathing
3
A client who was in a motor bike accident has a severe neck injury. Which priority nursing care is most needed? 1 Assessing for crepitus 2 Assessing for bleeding 3 Maintaining a patent airway 4 Performing neurologic assessment
3
A nurse is making notes on the changing conceptual abilities that accompany the transition of children from the preschool years into the school years. Which action should the nurse expect to be in line with the conceptual abilities of preschoolers? 1 Seeing things from another's point of view 2 Properly verbalizing how they found their way to a friend's house 3 Correctly arranging a graduated set of circles from largest to smallest on a stick 4 Performing a set of actions mentally without the need to carry out the behaviors
3
A nurse's best approach when caring for a confused older client is to provide an environment with what? 1 Space for privacy 2 Group involvement 3 Trusting relationships 4 Activities that are varied
3
A client with vascular dementia (formerly known as multiinfarct dementia) has signs and symptoms that are different from dementia of the Alzheimer type. What characteristics unique to vascular dementia should the nurse expect when assessing a client with this diagnosis? Select all that apply. 1 Memory impairment 2 Failure to identify objects 3 Exaggerated deep tendon reflexes 4 Episodic progression of symptoms 5 Inability to use words to communicate
3,4
A nurse administers oxygen at 2 L/min via nasal cannula to a client with emphysema. Which clinical indicators should the nurse closely observe in the client? Select all that apply. 1 Anxiety 2 Cyanosis 3 Drowsiness 4 Mental confusion 5 Increased respirations
3,4
A client states, "I get down on myself when I make a mistake." In a cognitive therapy approach, which nursing interventions are most appropriate? Select all that apply. 1 Teaching the client relaxation exercises to diminish stress 2 Exploring with the client past experiences that have caused distress 3 Providing the client with mastery experiences designed to boost self-esteem 4 Encouraging the client to replace these negative thoughts with positive thoughts 5 Helping the client modify the belief that anything less than perfection is unacceptable
4,5