cognition study questions
A 7-year-old child presents to the primary care office for a routine physical. Which question should the nurse include during the interview to identify the need for education related to preventing potential cognitive disorders? A) "Do you wear a helmet when you ride a bicycle or skateboard?" B) "How many times per day do you brush your teeth?" C) "How are your grades in school?" D) "How many hours per day do you watch television?"
Answer: A Explanation: A) Nurses accomplish prevention and protective measures through teaching and providing anticipatory guidance. An example of an independent intervention is ensuring that children wear their bicycle helmets to aid in prevention of head trauma that could lead to cognitive abnormalities. The other options are important to assess but are irrelevant to impaired cognition.
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
Answer: A Explanation: Appropriate nursing diagnoses may depend on the stage of Alzheimer disease (AD). Impaired Memory is an appropriate nursing diagnosis in stage 1 AD. Caregiver Role Strain is appropriate for any stage of AD. Functional Family Processes and Ineffective Coping are not diagnoses related to cognitive behavioral assessment. Pseudohostility is not a nursing diagnosis.
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."
Answer: A Explanation: Currently no treatment has been found to reverse or stop the pathologic process in progressive dementia. Studies on the use of dietary supplements such as antioxidant vitamins, gingko biloba, resveratrol, omega-3 fatty acids, and medical food such as tramiprosate (Vivimind) and caprylic acid for the management of AD are inconclusive at best and associated with risks such as interaction with other drugs and toxicity. There are two classes of medications used to slow the progression of the disease.
The nurse is caring for the client prescribed thorazine. Which assessment findings alert the nurse to the possibility that the client has developed tardive dyskinesia? Select all that apply. A) Wormlike motions of the tongue B) Lip smacking C) Unusual facial movements D) Muscle spasms of the neck E) Shuffling gait
Answer: A, B, C Explanation: Tardive dyskinesia is characterized by unusual tongue and face movements such as lip smacking and wormlike motions of the tongue. Severe muscle spasms of the back, neck, and tongue are known as acute dystonia, not tardive dyskinesia.
The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia? 1. Use of confabulation 2. Improvement in sleeping 3. Absence of sundown syndrome 4. Presence of personal hygienic care
1 Rationale: The clinical picture of dementia ranges from mild cognitive deficits to severe, life-threatening alterations in neurological functioning. For the client to use confabulation or the fabrication of events or experiences to fill in memory gaps is not unusual. Often, lack of inhibitions on the part of the client may constitute the first indication of something being "wrong" to the client's significant others (e.g., the client may undress in front of others, or the formerly well-mannered client may exhibit slovenly table manners). As the dementia progresses, the client will have difficulty sleeping and episodes of wandering or sundowning. Often, a lack of hygiene care may be noted in a client with dementia. Test-Taking Strategy: Focus on the client's diagnosis and note the subject, a manifestation of dementia. Think about the characteristics of dementia to direct you to the correct option.
The nurse notes that an older client with dementia is unable to care for self to bathe and perform other activities of daily living (ADL). Which is an appropriate goal for this client? 1. The client will function at the highest level of independence possible. 2. The client will be admitted to a long-term care facility to have ADL needs met. 3. The nursing staff will attend to all the client's ADL needs during the hospital stay. 4. The client will complete all ADL independently within a 1-hour time frame.
1 Rationale: All clients, regardless of age, need to be encouraged to perform at the highest level of independence possible. Independence contributes to the client's sense of control and well-being. Option 2 is incorrect because what the self-care deficit entails is not known. To assume that the client requires long-term care based on so little information would be erroneous. Options 3 and 4 use the word all and are closed-ended statements. Test-Taking Strategy: Focus on the subject, a goal for a client who is unable to care for self. Eliminate options 3 and 4 first because of the closed-ended word "all". From the remaining choices, select option 1 because it is the umbrella option.
Which situation will present the most prominent problem when attempting to manage the outpatient care of a client diagnosed with schizophrenia? 1. The client's noncompliance with medication therapy 2. The community's opposition to outpatient mental health clinics 3. The associated increased risk that the client may become homeless 4. The family's negative reaction to transferring the client to community-based care
1 Rationale: Clients often forget to take their medications as scheduled, and this is the most prominent problem since medication therapy is vital to the function of clients with such a diagnosis. While the situations described in the remaining options may occur, these problems are not as impacting on the client's prognosis and can be addressed and often controlled. Test-Taking Strategy: Note the strategic word, most. Eliminate options 2 and 4 first as they are comparable or alike. To select from the remaining options, recalling that medication therapy is a primary focus in the management of schizophrenia will assist in answering correctly.
The nurse is developing a plan of care for a client with late-stage Alzheimer's disease. The nurse identifies which client problem as having the highest priority? 1. Risk for injury 2. Social isolation behaviors 3. Role performance alterations 4. Inability to communicate verbally
1 Rationale: Clients who have Alzheimer's disease have significant cognitive impairment and are therefore at risk for injury. It is critical for the nurse to maintain a safe environment, particularly as the client's judgment becomes increasingly impaired. Options 2, 3, and 4 may be appropriate, but the highest priority is directed toward safety. Test-Taking Strategy: Note the use of the strategic words, highest priority. Use Maslow's Hierarchy of Needs theory. When a physiological need is not addressed, safety needs receive priority. This will direct you to the correct option.
The nurse determines that a history of which mental health disorder would support the prescription of taking donepezil hydrochloride? 1. Dementia 2. Schizophrenia 3. Seizure disorder 4. Obsessive-compulsive disorder
1 Rationale: Donepezil hydrochloride is a cholinergic agent that is used in the treatment of mild to moderate dementia of the Alzheimer's type. It increases concentration of acetylcholine, which slows the progression of Alzheimer's disease. The other options are incorrect and are not indications for use of this medication. Test-Taking Strategy: Focus on the subject, the condition that is treated with donepezil hydrochloride. Remember that this medication is used to treat dementia to assist you in answering questions similar to this one.
The nurse is planning relapse prevention information for a client diagnosed with schizophrenia. The nurse understands that it is important to ensure which primary intervention? 1. Including the client's support system in the teaching 2. Facilitating weekly maintenance therapy for the client 3. Having the client restate discharge goals and strategies 4. Stressing the importance of client compliance with the medication plan
1 Rationale: Of the options provided, including the client's support system in the teaching has the greatest effect on relapse prevention management because it will provide the client with valuable support. Although the remaining options are helpful, they all focus on the client's having the resources and abilities to be self-managing and self-reflective. Test-Taking Strategy: Note the strategic word, primary. Focus on the subject, relapse prevention. Recalling the importance of a support system will direct you to the correct option.
The primary health care provider (PHCP) has written a prescription to start progressive ambulation as tolerated in a hospitalized client who experiences periods of confusion because of bed rest and prolonged confinement to the hospital room. Which nursing intervention would be appropriate when planning to implement the PHCP's prescription and address the needs of the client? 1. Progressively ambulate the client in the hall 3 times daily. 2. Ambulate the client in the room for short distances frequently. 3. Ambulate the client to the bathroom in his or her room 3 times daily. 4. Assist with range-of-motion exercises 3 times daily to increase strength.
1 Rationale: The cause of the confusion in this situation is bed rest and decreased sensory stimulation resulting from prolonged confinement; therefore, it is best to ambulate the client in the hall. This will increase sensory stimulation and may decrease confusion. Ambulating in the room and to the bathroom in the client's room will not address the client's need for sensory stimulation. Range-of-motion exercises are an action that would have been performed in preparation for ambulation while the client was on bed rest. Test-Taking Strategy: Focus on the subject, confusion resulting from bed rest and prolonged confinement. Eliminate option 4 first because this action would have been carried out in preparation for ambulation while the client was on bed rest. Next eliminate options 2 and 3 because they are comparable or alike in that they both address ambulating the client in the hospital room.
The nurse is planning care for a client who displays confusion secondary to a brain attack (stroke). Which approaches by the nurse would be helpful in assisting this client? Select all that apply. 1. Providing sensory cues 2. Giving simple, clear directions 3. Providing a stable environment 4. Keeping family pictures at the bedside 5. Encouraging family members to visit at the same time
1, 2, 3, 4 Rationale: Clients with cognitive impairment from neurological dysfunction respond best to a stable environment that is limited in amount and type of sensory input. The nurse can provide sensory cues and give clear, simple directions in a positive manner. Confusion can be minimized by reducing environmental stimuli (such as television or multiple visitors) and by keeping familiar personal articles (such as family pictures) at the bedside. Test-Taking Strategy: Read the question carefully, and note the client's diagnosis. Focus on thesubject, helpful approaches. Remember that the client who is confused can handle only limited amounts of information at a time
Which behavior in a client with schizophrenia demonstrates the client's cognitive inability to appropriately process data from external stimuli? 1. The client remains in the same physical position for hours. 2. The client is convinced that the curtains are actually ghosts. 3. The client looks for a cat when someone says, "It's raining cats and dogs." 4. The client repeatedly asks, "Can you see my dead sibling over by the door?"
2 Rationale: A delusion is a personal belief that is the product of dysfunctional processing of information derived from external reality. This cognitive processing dysfunction is the basis of schizophrenia. Catatonia is a stuporous state that renders the client incapable of physical movement. Magical thinking is a result of concrete thinking that causes the client to interpret a statement literally. Hallucinations are the result of distortions in perceptions of the senses, but they are not reliant on internal or external stimuli. Test-Taking Strategy: Focus on the subject, the result of dysfunctional processing in a client with schizophrenia. Eliminate options 1, 3, and 4 because they are focused on an aspect (physical movement, magical thinking, hallucinations) other than the processing of informational data.
The nurse is evaluating a function of the limbic system as a part of the neurological status of a client. What would the nurse assess? 1. Experience of pain 2. Affect or emotions 3. Response to verbal stimuli 4. Insight, judgment, and planning
2 Rationale: Affect and emotions are part of the role of the limbic system and involve both hemispheres of the brain. Pain is a complex experience involving several areas of the central nervous system. The response to verbal stimuli is part of the level of consciousness, which is under the control of the reticular activating system and both cerebral hemispheres. Insight, judgment, and planning are part of the functions of the frontal lobes of the brain in conjunction with association fibers connecting to other areas of the cerebrum. Test-Taking Strategy: Focus on the subject, the function of the limbic system. To answer this question correctly, you must be familiar with the different areas of the brain and the control they have over various areas of function. Remember that affect and emotions are part of the role of the limbic system.
The nurse caring for a client diagnosed with schizophrenia would include which interventions in the plan of care to assist in managing the client's concrete thinking? 1. Provide the client with written instructions regarding the routine of the unit. 2. Present verbal instructions regarding expectations in single, simple commands. 3. Assess the client's understanding of instructions by requiring restatement of expectations. 4. Incorporate family members in determining the emotional and physical needs of the client.
2 Rationale: A client with concrete thinking often has difficulty with multiple-step tasks and commands. The information would be provided in clear, concise, and single-focused commands to minimize client confusion and maximize understanding. The client may be incapable of processing information in written form and is unlikely able to restate directions because of thought process dysfunction. These methods do not address the limitations of concrete thinking. Using family to help determine the client's needs may be an appropriate intervention, but this is not directed at minimizing the effect of the client's altered thought processes. Test-Taking Strategy: Focus on the subject, interventions to manage the client's concrete thinking. Eliminate options that are dependent on the client possessing intact cognitive functioning, which is something lacking in a client exhibiting concrete thinking. Also eliminate any option that does not address the need to encourage client autonomy but rather has the family assume the responsibility.
The nurse is caring for an older client following surgical repair of a hip fracture. On assessment of the client, the nurse notes that the client is disoriented and is attempting to get out of bed. Which is the most appropriate initial nursing intervention? 1. Apply restraints to the client. 2. Place a mattress sensor pad on the bed. 3. Have the assistive personnel check on the client every half-hour. 4. Collaborate with the primary health care provider for a prescription for a sedative.
2 Rationale: A client would not be placed in a physical restraint or sedated just because he or she is older and disoriented. Alternative methods would be used before applying any types of restraints. For example, a mattress sensor pad will alert the nursing staff of movement. Physical restraints may cause further disorientation and would not be applied unless specifically prescribed. Agency policies and procedures need to be followed before the application of restraints. Test-Taking Strategy: Note the strategic words, most appropriate initial. Eliminate option 3 first because the interval is not frequent enough when a client is disoriented and attempting to get out of bed. Next eliminate option 1 because it is a serious intervention and would be analyzed for its risk versus its benefit. Finally eliminate option 4, which indicates that a prescription for a chemical restraint will be obtained. This leaves you with the remaining correct option.
An older client in an acute state of disorientation is brought to the hospital emergency department by the client's daughter. The daughter states that the client was "clear as a bell this morning." The nurse determines from this piece of information that which is an unlikely cause of the disorientation? 1. Hypoglycemia 2. Alzheimer's disease 3. Medication dosage error 4. Impaired circulation to the brain
2 Rationale: Alzheimer's disease is a chronic disease with progression of memory deficits over time. The situation presented in the question represents an acute problem. Evaluation is necessary to determine whether hypoglycemia, medication use, or impaired cerebral circulation has had a role in causing the client's current symptoms. Test-Taking Strategy: Focus on the subject, the cause of the disorientation. Note the words clear as a bell this morning and unlikely. Eliminate options 1, 3, and 4 because they are comparable or alike and can trigger an acute confusional state.
The nursing instructor is discussing the topic of pain with a student nurse who is assessing the status of pain in a cognitively impaired older adult. What comment by the student implies that further education is needed? 1. Older adults tend to report pain less often than do younger adults. 2. Clients in this age group are less sensitive to pain and have a greater pain tolerance. 3. Mental images of pain are a less effective means to assess pain in this group than visual representations. 4. Pain in the cognitively impaired older adult may require more frequent assessments than in clients who are not impaired.
2 Rationale: Cognitive impairment in the older adult acts as a barrier to pain assessment, and pain may be more accurately reported at the moment when it occurs than when prompted by the nurse. Clients in this age group are not less sensitive to pain and do not necessarily have a greater pain tolerance. The other options are correct statements. Test-Taking Strategy: Focus on the subject, care of the older client. Recall the physiological changes of the aging process. Then note the strategic words, further education is needed. This indicates a negative event query and directs you to select an incorrect statement. Also focus on the data in the question, cognitively impaired older adult, to direct you to the correct option.
During the admission assessment process, the nurse observes that a client diagnosed with paranoid schizophrenia has multiple dental caries and mouth ulcers. The client denies oral pain or difficulty eating and does not present any concern over the nurse's finding. The nurse recognizes the client's response as most likely the result of which client factor? 1. Apathy 2. Impaired pain perception 3. Distrust of authority figures 4. Poor verbal communication skills
2 Rationale: Commonly, schizophrenia's effect on the pain center in the brain results in poor pain recognition. The client is likely not experiencing oral pain to the degree that may be felt by the individual who does not have schizophrenia. Although the remaining options may be general factors affecting this client's perceptions and personal interactions, they are not related to the pain perception threshold. Test-Taking Strategy: Note the strategic words, most likely. Focus on the subject, that the client denies oral pain or difficulty eating. Understanding of the brain dysfunction associated with schizophrenia and its effect on pain perception will assist you to eliminate options 1, 3, and 4.
A client diagnosed with delirium becomes disoriented and confused at night. Which intervention would the nurse implement initially? 1. Move the client next to the nurses' station. 2. Use an indirect light source and turn off the television. 3. Keep the television and a soft light on during the night. 4. Play soft music during the night and maintain a well-lit room.
2 Rationale: Provision of a consistent daily routine and a low-stimulating environment is important when a client is disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses' station may become necessary but is not the initial action. Test-Taking Strategy: Note the strategic word, initially. Eliminate options that are inappropriate or premature actions and may increase stimulation and add to the confusion. This will direct you to the correct option.
The nurse is caring for a client diagnosed with Alzheimer's disease. The nurse would anticipate that the client has changes in which component of the nervous system? 1. Glia 2. Peripheral nerves 3. Neuronal dendrites 4. Monoamine oxidase
3 Rationale: Alzheimer's disease is characterized by changes in the dendrites of the neurons. The decrease in the number and composition of the dendrites is responsible for the symptoms of the disease. The components in the other options are not related to the pathology of Alzheimer's disease. Test-Taking Strategy: Focus on thesubject, the pathophysiology associated with Alzheimer's disease. Recalling that Alzheimer's disease is caused by problems in the central nervous system, not the peripheral nervous system, and that it is a problem with neuronal dendrites will direct you to the correct option
The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information? 1. Apply restraints to the client. 2. Ask the family to stay with the client. 3. Place a clock and calendar in the client's room. 4. Ask the laboratory to perform electrolyte studies.
3 Rationale: An inactive older adult may become disoriented because of lack of sensory stimulation. The most appropriate nursing intervention would be to reorient the client frequently and to place objects such as a clock and a calendar in the client's room to maintain orientation. Restraints may cause further disorientation and would not be applied unless specifically prescribed; agency policies and procedures need to be followed before the application of restraints. The family can assist with orientation of the client, but it is inappropriate to ask the family to stay with the client. It is not within the scope of nursing practice to prescribe laboratory studies. Test-Taking Strategy: Note the strategic word, best, and eliminate option 4 first because it is not within the realm of nursing practice to prescribe laboratory studies. Next, eliminate option 1 because restraints may add to the disorientation that the client is experiencing. It is inappropriate to place the responsibility of the client on the family, so eliminate option 2. Also, note the relationship between the word disoriented in the question and the implications of reorientation in the correct option.
Which goal addresses the therapeutic management needs of a client with schizophrenia who is experiencing hallucinations? 1. Support the client through the hallucination in a caring, therapeutic manner. 2. Provide the client with insight as to why they may be experiencing the hallucination. 3. Facilitate the client's awareness that the hallucination is not the reality of the world. 4. Help the client to ignore the hallucination through appropriate coping mechanisms.
3 Rationale: The goal of nursing interventions for the therapeutic management of hallucinations is to first help the client increase awareness so that they can distinguish between the misperception and reality. Having insight into why the hallucinations occur and possessing strategies to manage them effectively are skills needed to attain the stated goal of awareness of reality. Ignoring a hallucination is inappropriate and can be harmful. All nursing interventions would be provided with care and in a therapeutic manner; this is not a client-oriented goal but a nursing responsibility. Test-Taking Strategy: Focus on the subject, hallucination management. Recalling the basis of a hallucination and noting the word reality in option 3 will direct you to this option.
When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse plans care based on which purpose of this approach? 1. Providing a supportive environment 2. Examining intrapsychic conflicts and past issues 3. Emphasizing social interaction with clients who withdraw 4. Helping the client to examine dysfunctional thoughts and beliefs
4 Rationale: Cognitive behavioral therapy is used to help the client identify and examine dysfunctional thoughts and to identify and examine values and beliefs that maintain these thoughts. The remaining options, while therapeutic in certain situations, are not the focus of cognitive behavioral therapy. Test-Taking Strategy: Focus on the subject, the purpose of a cognitive behavioral approach. Note the relationship between the word cognitive in the question and thoughts in the correct option.
The nurse is developing a plan of care for a client with a diagnosis of early-stage Alzheimer's disease. The plan of care would include nursing interventions that address which early characteristic of Alzheimer's disease? 1. Confusion is common. 2. The client may wander. 3. The client may be easily frustrated. 4. Forgetfulness interferes with the daily routine.
4 Rationale: In early Alzheimer's disease, forgetfulness begins to interfere with daily routines. The client has difficulty concentrating and difficulty learning new material. Options 1, 2, and 3 are characteristics of this disorder but occur later as the disease progresses. Test-Taking Strategy: Note thestrategic word,early.Focus on the diagnosis and the characteristics associated with this disease to direct you to the correct option. Remember that forgetfulness is one of the earliest signs
Which assessment finding would be a manifestation associated with dementia? 1. Catatonia 2. Confabulation 3. Presence of ritualistic behaviors 4. Increased display of inhibited behaviors
4 Rationale: The clinical picture of dementia varies from the development of mild cognitive defects to severe, life-threatening alterations in neurological functioning. For the client to use confabulation or fabrication of events or experiences to fill in memory gaps is common. Ritualistic behaviors are associated with obsessive-compulsive disorder, while catatonia is a psychotic reaction. Often, lack of inhibition on the part of the client constitutes the first indication to the client's significant others that something is "wrong." Test-Taking Strategy: Focus on the subject, manifestation associated with dementia. Think about the psychopathology associated with dementia to assist in answering correctly. Remember that it is common for the client to use confabulation or fabrication of events or experiences to fill in memory gaps.
An older resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My parent is waiting to take me for a ride." Which is the appropriate response by the nurse? 1. "I need you to sign a form before leaving." 2. "You will get sick if you go out in the rain." 3. "How old are you? Your parent must no longer be living." 4. "Let's have a cup of coffee, and you can tell me about your parent."
4 Rationale: The correct response acknowledges the client's comment and behavior. Allowing the client to leave after forms are signed fails to protect the client from possible harm. The remaining options do not preserve the client's dignity. Test-Taking Strategy: Use therapeutic communication techniques. Eliminate first the option that fails to protect the client or the client's rights. From the remaining options, note that the correct option focuses on the client's comment and behavior.
The nurse is conducting a neurological assessment, including a health history, on a client with a neurological disorder. The nurse observes that the client is having difficulty answering the questions and would perform which action? 1. Ask a second nurse to be present during the interview. 2. Defer both the health history and the neurological examination. 3. Defer the health history and proceed with the neurological examination. 4. Ask the client to give permission for a family member to stay during the interview.
4 Rationale: The health history and physical assessment for a client with a neurological problem are very similar to those for any other client, with perhaps a more intense neurological examination. If the client is confused or agitated or has difficulty hearing or speaking, the nurse would ask the client to give permission for a family member or significant other to stay with him or her during the history taking to ensure accurate data. Deferring the health history and/or neurological examination will not obtain the assessment data. Having a second nurse present is of no benefit. Test-Taking Strategy: Focus on the subject, conducting a neurological assessment on a client who is having difficulty answering the questions. The only option that will assist in obtaining assessment data is the correct one. In addition the correct option asks the client for permission, a client's right.
An older client is brought to the hospital emergency department by a neighbor who heard the client talking and found him wandering in the street at 3 a.m. The nurse would first determine which data about the client? 1. His insurance status 2. Blood toxicology levels 3. Whether he ate his evening meal 4. Whether this is a change in usual level of orientation
4 Rationale: The nurse would first determine whether this behavior represents a change in the client's neurological status. The next item to determine is when the client last ate. Blood toxicology levels may or may not be needed, but the health care provider would likely prescribe these. Insurance information must be obtained at some point but is not the priority from a clinical care viewpoint. Test-Taking Strategy: Use knowledge about neurological assessment to answer this question. Note the strategic word, first. Focusing on the data in the question will direct you to the correct option, which is focused on the client's neurological status.
The nurse is caring for a client diagnosed with Alzheimer's disease who is demonstrating characteristics of agnosia. Which client behavior supports the presence of this cognitive deficiency? 1. The client has difficulty with balance when rising from the chair. 2. The client has lost the cognitive ability to fold fold own clothes. 3. The client recognizes children but has difficulty calling them by name. 4. When asked to pick up the cup, the client consistently fails to identify the cup.
4 Rationale: When illness (Alzheimer's disease) affects the temporal-parietal-occipital association cortex, the client may experience the inability to identify well-known objects and people. This is called agnosia. Ataxia describes altered motor function. The client also may experience difficulty finding the right word to use, called aphasia, and an inability to perform familiar skilled activities, called apraxia. Test-Taking Strategy: Focus on the subject, care of the client with Alzheimer's disease. Focus on the description of the client's behavior in the question. Recalling the names of the conditions described in each of the options will direct you to the correct option.
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
Answer: A Explanation: Certain medications, such as hypnotics/sedatives, anxiolytics, antidepressants, anti-Parkinson drugs, anticonvulsants, or antispasmodics, also increase symptoms of delirium. Therefore, the client's medication must be reviewed to determine the effects of drugs and cognitive changes. Although loss of a loved one may result in depression, it is unlikely to be the source of confusion. Age alone does not cause confusion, and cardiac disease alone would not cause confusion.
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
Answer: A Explanation: Damage to the client's temporal lobe manifests as impaired memory, difficulty learning new things, and receptive aphasia. Damage to the limbic system manifests as loss of memory, fluctuating emotions, depression, and difficulty learning new information. Damage to the frontal lobe manifests as problems with intentional movement, fluctuating emotions, and loss of the ability to walk. Frontal lobe damage also causes loss of the ability to talk and the ability to swallow. Damage to the occipital lobe results in loss of reading comprehension and hallucinations.
The nurse is running a group therapy session for clients diagnosed with schizophrenia. Which interventions address the cognitive deficits associated with this disorder? A) Have clients wear name tags. B) Provide a highly stimulating environment. C) Encourage open-ended activities. D) Use humor.
Answer: A Explanation: Facial agnosia is a cognitive alteration frequently associated with schizophrenia. Name tags assist clients to remember other group members' names and may foster social interaction. Decreased stimuli would address deficits in focus and attention. Structured activities and cues are required to address lack of spontaneity in speech. Individuals with schizophrenia may have concrete thinking and may not respond well to humor.
The nurse is caring for a client with schizophrenia whose symptoms of psychosis have resolved. The client's family complains that the client's hygiene remains poor and he lacks motivation and initiative. Which conclusion by the nurse is most appropriate? A) The client is experiencing negative symptoms. B) The client is experiencing disordered thinking. C) The client was misdiagnosed. D) The client is most likely hearing voices.
Answer: A Explanation: Negative symptoms are those that subtract from normal behavior. These symptoms include a lack of interest, motivation, responsiveness, pleasure in daily activities, or the ability to care for self. Positive symptoms include hallucinations, delusions, and a disorganized thought or speech pattern. There isn't any evidence to support that the client is hearing voices. There isn't any evidence to support that the client is very depressed.
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."
Answer: A Explanation: People who cannot hear or see well often appear confused. The nurse should assess whether the client is having difficulty with these prior to moving on in the assessment process. Determine the degree of impairment and explore the possibility that this hearing impairment may be contributing to the client's confusion. A nurse should never discount the client's concerns, and memory loss with confusion and forgetfulness is not part of the normal aging process. The nurse needs to explore further before an expensive diagnostic study is considered. It would be beyond the scope of practice for the nurse to recommend this testing.
Which cognitive development theory proposes that all children progress through the same stages of development? A) Piaget B) Vygotsky C) Information-processing D) Erickson
Answer: A Explanation: Piaget's cognitive development theory proposes that all children progress through the same stages of development. Vygotsky's theory, on the other hand, discards the idea that all children progress through the same stages of development. Instead, Vygotsky theorized that skill development is influenced by the child's environment and culture. The information-processing theory views the mind as a computer that is always changing and evolving and takes in information, operates on it, and converts it to answers. Erickson's theory is not a cognitive development theory, but rather is a behavioral development theory.
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
Answer: A Explanation: Stage 2 clients are generally more confused, can demonstrate repetitive behavior, are less able to make simple decisions and to adapt to environmental changes, and are often unable to carry out activities of daily living. The spouse needs opportunities to obtain the sleep and nutrition necessary to preserve personal health. Because the stage 2 client does not adapt well to changes in the environment, it would be best to have someone come into the home, rather than to have the client go out. An outing or a list of activities would be better suited for the client in stage 1. Recommending placement in long-term care might be premature and is not up to the nurse.
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.
Answer: A Explanation: The client "does not sustain injury during wanderings" is the correct answer because it relates to the diagnosis and is measurable. The client "maintains continence on four out of five voidings" does not relate to the diagnosis. The client "sleeps through the night and stays awake most of the day" does not relate to the diagnosis. The client "receives culturally appropriate care" is an incorrect answer because expected outcomes are unknown and not measurable.
While assessing the cognitive status of a school-age child, the nurse notes that the child was unable to perform basic mathematical problems and unable to name several former presidents of the United States. Prior to considering the possibility that this client has cognitive issues, which factor should be reviewed? A) The child's age and developmental status B) The child's living arrangements with separated parents C) The child's currency of vaccinations D) The child's hobbies performed in leisure time
Answer: A Explanation: The nurse must consider a pediatric client's level of cognitive development before asking questions that involve calculation, judgment, or abstract thought. Even children with normal cognition will be unable to respond appropriately if they have not yet achieved the level of development necessary for these activities. The child's home environment, currency of vaccinations, and hobbies will not explain why the child is unable to correctly respond to questions having to do with complicated math or history.
Which statement regarding the pathophysiology and etiology of schizophrenia is correct? A) "Brain imaging shows that there is reduced blood flow to the thalamus, frontal lobe, and temporal lobes." B) "There is an increased number of nicotinic receptors in the hippocampus, which makes it harder to form new memories and interpret sensory stimuli." C) "Genetics does not seem to factor into the cause of the disease." D) "The ventricles and sulci of the brain are decreased in size."
Answer: A Explanation: There are many abnormalities of the central nervous system in a client with schizophrenia. Brain imaging studies of individuals with schizophrenia consistently reveal a pattern of structural abnormalities that include decreased volumes of gray matter in the prefrontal cortex, temporal lobes, hippocampus, and thalamus; enlarged ventricles and sulci; and decreased blood flow to the frontal lobe, thalamus, and temporal lobes. A decreased number of nicotinic receptors in the hippocampus makes it harder for the client with schizophrenia to form new memories and interpret sensory stimuli. Genetics seems to factor into the cause of the disease, as familial patterns of the disease are noted. In the client with schizophrenia, the ventricle and sulci of the brain are increased in size.
The nurse is teaching techniques to improve communication skills to a family with a member with schizophrenia. Which techniques should be included? Select all that apply. A) Use active listening. B) Making positive, specific requests for change. C) Use "I" language to express feelings. D) Encourage client to communicate with only family. E) Use "you" statements to point out negative behavior.
Answer: A, B, C Explanation: Increasing communication in a safe setting with family and friends helps to stimulate both self-confidence and the fostering of important relationships. Use "I" language to express positive feelings (e.g., "I am happy when you decide to sit down for dinner with us"). Engage in active listening (e.g., asking questions and nodding in agreement when another person speaks). Make positive, specific requests for change that are linked to emotions (e.g., "I would really like it if you could play a game with us tonight"). Express negative feelings with "I" rather than "you" language (e.g., saying "I'm worried that you may not be getting enough sleep" instead of "You never get enough sleep at night").
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)
Answer: A, B, C, D Explanation: Grieving over the diagnosis and loss of functioning and mental abilities will be an ongoing process for the client and the family members and is therefore a goal. While the client is still cognizant, it is important that the client and family discuss the desired treatment and designate a healthcare proxy to carry out the client's wishes regarding the treatment. Clients with early Alzheimer disease should start the cholinesterase inhibitor medication as soon as possible to extend the early stage of the disease. During this time period, the home environment should be modified to balance safety with client autonomy. Clients in stage 1 of Alzheimer disease continue to be proficient with ADLs and do not require assistance.
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
Answer: A, B, C, E Explanation: The most prominent risk factor for Alzheimer disease is advancing age. Individuals with a family history of AD are more likely to develop the disease, even in the absence of known genetic factors that predict or increase the risk of the disease. Research has identified risk factors of AD to include cardiovascular risks such as diabetes, mid-life obesity, mid-life hypertension, and hyperlipidemia. AD is almost three times more common in women than men. There is no indication that hearing deficits play a role in the development of Alzheimer disease.
An adolescent client is admitted to the hospital for the treatment of schizophrenia. The client's mother is confused and wants to know what she did to cause this to occur. Which responses by the nurse are appropriate? Select all that apply. A) "Schizophrenia is a biological brain disorder." B) "Research indicates that schizophrenia is a genetic disorder." C) "Research indicates that a very stressful environment causes schizophrenia." D) "Schizophrenia is due to too much dopamine in certain parts of the brain." E) "Schizophrenia is linked to drinking alcohol during pregnancy."
Answer: A, B, D Explanation: Theories explaining the cause of schizophrenia include a genetic component, imbalances in neurotransmitters in specific areas of the brain, and overactive dopaminergic pathways in the basal nuclei. There is no evidence to support a link between schizophrenia and alcohol consumption during pregnancy. A stressful environment will exacerbate the symptoms of schizophrenia but does not cause the illness.
The nurse is providing education related to improving family dynamics for the family of an adolescent diagnosed with schizophrenia. Which topics should be included in the teaching? Select all that apply. A) Establish boundaries B) Identify coping mechanisms C) Discuss childhood memories D) Prevent future episodes E) Improve communication
Answer: A, B, E Explanation: The goal is to help clients and families cope, improve their communication and interpersonal skills, establish boundaries, and moderate family cohesion and flexibility. The family may not be able to prevent future psychologic episodes. Discussing childhood memories is irrelevant to treatment.
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
Answer: A, C, D Explanation: Evidence demonstrates that cognitive activities such as reading, completing puzzles, and learning new information or tasks build cognitive resilience and protect against cognitive decline. There is some evidence to suggest that the heart-healthy diets that include antioxidant- and polyphenol-rich foods such as tea, cocoa, grapes, and colorful fruits and vegetables may interrupt formation of amyloid plaques and prevent AD. Social engagement may improve cognitive function and have some protective effects against AD. Modest levels of exercise have been demonstrated to improve cognitive function. Moderate alcohol consumption may be protective against AD. However, evidence is insufficient to suggest that individuals who do not already drink should start drinking.
Damage to which region of the brain may result in loss of recent memory? A) Neuron B) Hippocampus C) Cerebrum D) Neurotransmitter
Answer: B Explanation: A) The structure that plays a role in memory is the hippocampus, located in the limbic system of the brain. A neuron carries and processes information within the nervous system. The cerebrum is the largest region of the brain. A neurotransmitter is a chemical messenger within the nervous system.
A client with dementia is prescribed donepezil (Aricept). Which should the nurse consider when teaching this client about the medication? A) Donepezil shortens the early stages of Alzheimer disease. B) Donepezil is an acetylcholinesterase inhibitor that has a modest effect in slowing the progression of Alzheimer disease. C) Donepezil is an anticholinergic and has been known to eradicate some of the symptoms associated with Alzheimer disease. D) Donepezil should be taken on an empty stomach. Answer: B
Answer: B Explanation: Acetylcholinesterase inhibitors reduce acetylcholine breakdown and have a modest effect in slowing an individual's rate of cognitive decline in Alzheimer disease. Symptoms are not eradicated, but progression is slowed. These medications should be taken on a full stomach, and antiemetic medications may also be needed.
The client is receiving risperidone (Risperdal) for the treatment of schizophrenia. Which client statement indicates the medication is effectively treating the positive symptoms of schizophrenia? A) "I promise not to skip breakfast anymore." B) "I am not hearing the voices anymore." C) "I will start going to group therapy." D) "I feel better and I am ready to go home."
Answer: B Explanation: Among the therapeutic effects of risperidone (Risperdal) is the remission of a range of psychotic symptoms that include delusions, paranoia, auditory hallucinations, and irrational behavior. A client stating he feels better and is ready to go home, stating he will go to group therapy, or stating he will not skip breakfast does not indicate the remission of any psychotic symptoms.
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
Answer: B Explanation: Besides the prevention and management of the underlying medical condition, the presence of parents and family members has been found to reduce the incidence of delirium. All of the other interventions are important for the discharge planning of this client.
The nurse walks into the client room, and the client is confused and disoriented. Ten minutes prior, the client was oriented to person, place, and time and was not confused. Which nursing action is priority? A) Position client in supine position B) Assess vital signs and pulse oxygenation C) Ambulate client to encourage lung expansion D) Obtain urine for urinalysis
Answer: B Explanation: Decreased O2 reaching the brain may lead to cognitive impairment, coma, and death. A client demonstrating a rapid onset of confusion and disorientation will need to have vital signs, pulse oximetry, and airway assessed for signs of impaired perfusion. Ambulating a client demonstrating these symptoms would be premature and could cause additional harm if there is impaired oxygen perfusion. Although urinary tract infections may cause acute mental status changes, the priority action would not be to obtain urine for a urinalysis.
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."
Answer: B Explanation: Delirium is characterized by a rapid and abrupt onset of symptoms and caused by an underlying medical condition. Once the medical condition is treated, the delirium resolves. Although delirium is more common in older individuals, aging is not a cause of delirium. Impairments in short-term memory are more indicative of dementia. The fact that he had been independent has no bearing on his current symptoms.
The nurse is assessing an older adult client and observes that the client is having several cognitive problems, including memory and attention deficits and fluctuating levels of orientation. The nurse confirms with the family that the client's symptoms developed over a several-year period. The client's symptoms are commonly observed with which condition? A) Depression B) Dementia C) Intellectual disability D) Delirium
Answer: B Explanation: Dementia is a chronic progressive disorder characterized by memory impairments that develop slowly over a longer period of time. Depression is a mood disorder that is characterized by a dysphoric mood or loss of interest in usual activities. Delirium is an acute, abrupt-onset condition characterized by prominent disorientation, impaired attention, and memory deficits. Intellectual disability is defined as significant limitation in intellectual functioning and adaptive behaviors that occurs before the age of 18.
Which is true regarding the aging process and cognition? A) Generally, older adults' short-term memory changes significantly. B) Generally, many older adults have increased difficulty finding and rapidly listing words. C) The ability to use and understand word combinations declines steadily with age. D) The ability to acquire practical information declines steadily with age.
Answer: B Explanation: Older adults typically have more difficulty with cognitive functions, such as word retrieval and episodic memory. However, in general, older adults' short-term memory remains intact and the ability to use and understand word combinations remains intact as well. Most older adults are able to acquire practical information until their death.
An older adult client comes into the clinic for a pneumonia vaccine. During the client interview, the client reports occasionally having difficulty remembering some words, but denies any other concerns. The client is alert and oriented to time, person, and place, and most responses are appropriate. How should the nurse describe this client's cognitive changes? A) Memory impairment that may be related to cerebral ischemia B) Normal signs of aging C) Indicators of depression in the elderly D) Early symptoms of dementia
Answer: B Explanation: Older adults typically have more difficulty with cognitive functions, such as word retrieval and episodic memory; however, the impact on overall cognitive function should be minimal. The changes described for this client are normal signs of aging and not symptoms of dementia, depression, or ischemia. Dementia may present with additional symptoms of memory loss related to orientation and completing day-to-day tasks. Depression would show signs of flat affect, or withdrawal, and ischemia may show additional neurologic deficits.
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
Answer: B Explanation: Sundowning is understood as confusion that intensifies in the evening or at bedtime. The client can become increasingly agitated, disoriented, or even aggressive/paranoid or impulsive and emotional later in the day and at night. Delirium is a rapid-onset type of confusion. Aphasia is the inability to use or understand language. Psychosis is a mental disorder, and this client is not exhibiting signs of psychosis.
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
Answer: B Explanation: The diagnosis of Alzheimer disease is based on the client history and physical examination. There is currently no one test or procedure that makes the diagnosis of Alzheimer disease. As AD progresses and more neurons die, two characteristic abnormalities develop in the brains of affected individuals. The first is thick protein clots called neurofibrillary tangles, and the second is insoluble deposits known as amyloid plaques, but these changes are found at autopsy, not by a CT scan or blood test.
A nurse working in a psychiatric unit is caring for a client diagnosed with schizophrenia who manifests positive symptoms of the disease. Based on this data, which manifestation does the nurse expect to identify when providing care? A) Social withdrawal B) Hallucinations C) Anhedonia D) Concrete thinking
Answer: B Explanation: The major manifestations of schizophrenia are described as either positive symptoms or negative symptoms, depending on whether they involve the presence of unusual behaviors or the absence of typical behaviors. Hallucinations are a positive symptom; all other choices are negative symptoms.
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."
Answer: B Explanation: The structure of the client's environment should support cognitive functions. Aids for hearing or vision are necessary to prevent sensory loss or distortion. Familiar objects from home, such as slippers, robe, and photographs, may help with orientation. Easily read clocks, orientation boards, and a structured routine that includes physical activity and socialization without sensory overload will also help with orientation. Clients with delirium can exhibit hyperactivity when overstimulated.
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
Answer: B Explanation: This client is in stage 2 (moderate AD) because the client has lost the ability to live independently. In this stage, the client may be unable to choose appropriate clothing or prepare food and is at increased risk of someone taking advantage of him or her because of loss of cognition and lack of safety awareness. A client in stage 1 (mild cognitive impairment) is able to maintain living independently, but the client's memory lapses are apparent to others. In stage 3 (severe AD), individuals become unable to perform even basic activities of daily living (ADLs). AD is described in terms of three stages: stage 1 (early), stage 2 (moderate), and stage 3 (severe).
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."
Answer: B, C Explanation: Delirium is a reversible condition caused by an acute problem, such as infection, and can occur at any age. Dementia is a cognitive decline generally associated with an aging adult. Older adults are at higher risk for developing delirium, not younger adult females. Also, young children are at greater risk for developing delirium than adolescents because children's bodies are less equipped to cope with insults such as fever, infection, and toxin exposure.
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.
Answer: B, C Explanation: The nurse will want to explain that any febrile illness may cause symptoms of delirium and that this symptom will abate when the temperature returns to normal. The presence of parents and family members has been found to reduce the incidence of delirium as well as decrease family stress. Teaching the family how to care for the child during the hospitalization or upon discharge will not necessarily decrease their anxiety. Telling the family the confusion will not last long is not helping them to understand the nature of the symptom.
The family of an older adult client is concerned about the changes in the client's behavior. The client used to be a wonderful cook but now cannot even remember how to use a blender. For which causes of impaired cognitive function should the nurse assess the client? Select all that apply. A) Obesity B) Nutritional deficiencies C) Medication reactions D) Stroke E) Snoring
Answer: B, C, D Explanation: Any change or deviation from normal in an individual's cognitive function should be evaluated. Dementia can be caused or exacerbated by other conditions and variables, including metabolic problems, nutritional deficiencies, infections, poisoning, medications, and any conditions that compromise oxygenation and perfusion. Snoring and obesity are not conditions noted to result in impaired cognitive functioning.
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.
Answer: B, C, D, E Explanation: Memory difficulties are an early symptom of Alzheimer disease. It is suspected that chronic inflammation and excess free radicals may cause neuron damage, which contributes to the disease. Depression and aggressive behavior are common symptoms of the disease. Alzheimer disease accounts for about 80% of all dementias. The acetylcholinesterase inhibitors, not the glutamatergic inhibitors, are the most widely used class of drugs for treating the disease.
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.
Answer: B, E Explanation: All older clients, including those with Alzheimer disease (AD), are at increased risk for injuries such as falls. Shoes should fit and be supportive. Simplifying the home environment while keeping familiar furniture in the same space will reduce confusion and promote safety. Rugs and cords should be removed to prevent falls. The use of physical and pharmacologic restraints should be avoided. In early stages of dementia, clients with Alzheimer disease may continue to drive.
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."
Answer: C Explanation: Hospitalized clients are much more likely to experience delirium because of the presence of predisposing illnesses, exposure to multiple medical interventions that may contribute to cognitive changes, and being in an environment that is unfamiliar, stimulating, and not conducive to maintaining normal diurnal rhythms. Delirium is an acute rapid-onset condition with an etiology that can usually be traced to a known cause. The cause of delirium can often be determined, and removal of the cause will usually result in complete recovery. The symptoms of delirium are not similar to those of depression
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.
Answer: C Explanation: Although placement in a long-term care facility is not going to be the fate of all individuals with Alzheimer disease, it is a common one. Providing the information early in the disease process allows the family to make an informed choice. Nurses will need to provide reinforced education and referrals throughout the disease process, not just during the initial hospitalization. There is no plan to transfer the client at this time; adjustment would occur after the transfer.
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
Answer: C Explanation: Delirium is often the most prominent manifestation of conditions such as dehydration, respiratory tract infections, urinary tract infections, and urinary retention, and adverse drug events may occur in the absence of symptoms such as fever or discomfort. Hypertension, lower back strain, and cataracts are not conditions that are known to cause signs of confusion in older adults.
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
Answer: C Explanation: Individuals who are starting to experience language deficits may be able to slow this decline by working with a speech therapist. Physical therapy can help individuals improve their muscle tone, maintain coordination, and maintain their range of motion. Occupational therapy helps the client maintain the ability to perform many activities of daily living. Access to community organizations is facilitated through the use of social workers.
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.
Answer: C Explanation: The client with dementia benefits from a routine schedule of activities, including meal times. The client typically is better oriented when it is quiet. It is important keep the room lit during waking hours; the lights should not be dimmed during this time. B) The client with dementia benefits from a routine schedule of activities, including meal times. The client typically is better oriented when it is quiet. It is important keep the room lit during waking hours; the lights should not be dimmed during this time.
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."
Answer: C Explanation: The earlier the medications are started, the greater the effect they will have on the symptoms of Alzheimer disease. Current medications will only decrease symptoms for a short period of time. Drugs will not control symptoms for many years. The drugs for treatment of Alzheimer disease are no more dangerous than other drugs used for a long period of time.
The nurse is educating an adolescent client diagnosed with schizophrenia on predisposing risk factors. Which significant risk factor should the nurse include in the teaching? A) Summer birthdate B) Parents recently divorced C) Positive family history D) Lives in rural setting
Answer: C Explanation: The most significant risk factor for schizophrenia is a positive family history. There is evidence that individuals born in late winter may be at greater risk of developing the illness, possibly due to exposure to infection. Although stress can trigger the illness in certain susceptible individuals, it is not a risk factor itself. Living in a rural area is not a risk factor for schizophrenia
The nurse is caring for a client with perceptual disturbances who is becoming agitated. Which action should the nurse take first? A) Distract client by taking into the dayroom to watch television with other clients. B) Administer medications to sedate client before violent behaviors occur. C) Request client to go back to room and dim lights. D) Do nothing, as this is a normal manifestation of disturbed cognition.
Answer: C Explanation: The nurse who observes a client demonstrating visual disturbances and/or psychotic behaviors should intervene by decreasing the environmental stimulus. If overstimulated, the client with visual disturbances or psychosis may display agitation. The use of physical and pharmacologic restraints should be avoided. Taking the client into the dayroom to watch television with others may overstimulate the client, further increasing agitation, which may increase risk of violence toward others.
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
Answer: C, D Explanation: A) The client is experiencing acute confusion and is also at risk for injury according to the scenario presented. The scenario does not indicate the client is experiencing anxiety or ineffective coping. Autonomic dysreflexia is a syndrome of clients with spinal cord damage, which is not indicated for this client.
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
Answer: D Explanation: A) Use of cuing devices such as to-do lists, calendars, written schedules, and verbal reminders can aid in maintaining client's highest level of functioning. The other options are interventions for a client diagnosed with stage 3 AD.
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.
Answer: D Explanation: Environmental stimuli should be kept at a minimum for clients with dementia. A quiet environment will prevent sensory overload. Once the client is less agitated, the client can be directed to a less stimulating activity. Use of physical and pharmacologic restraints should be avoided.
The nurse is caring for a client who is experiencing auditory hallucinations. Which is the priority nursing diagnosis for this client? A) Disturbed Thought Processes B) Individual Ineffective Coping C) Impaired Verbal Communication D) Risk for Violence, Self-Directed or Other-Directed
Answer: D Explanation: Maintaining a safe environment is the priority diagnosis. When hallucinating or interpreting others' actions and statements from the standpoint of delusions, the client may believe herself to be in danger, regardless of whether there is a factual basis for her fear. Under such circumstances, both the client and perceived aggressors may be at risk for injury. Although the client has impaired thought processes, this is not the priority diagnosis at this time. Individual Ineffective Coping and Impaired Verbal Communication are also correct diagnoses, but the key word here is "priority," and this client has a potential or risk for harm to self or others.
The healthcare provider prescribes aripiprazole (Abilify) for the client with schizophrenia. Which is the priority outcome for the client? A) The client will report a decrease in auditory hallucinations. B) The client will report symptoms of restlessness. C) The client will consume adequate fluids and a high-fiber diet. D) The client will adhere to the medication regime
Answer: D Explanation: Medication compliance is a priority for clients with schizophrenia. Relapse of symptoms will occur without the medications. The symptom of restlessness is known as akathisia. This would be important to report, but it is not the priority outcome. Adequate fluids and fiber will decrease the side effect of constipation, but this is not the priority outcome. A decrease in auditory hallucinations is an expected effect of aripiprazole (Abilify), but this is not the priority outcome.
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."
Answer: D Explanation: Researchers are not sure why most cases of Alzheimer disease (AD) arise, although a variety of genetic and environmental factors appear to be involved. Alzheimer disease is not directly linked to smoking and alcohol intake. It is inappropriate to assume that other family members had the disorder but were misdiagnosed. Alzheimer disease has a predictable course with distinct phases or stages.
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
Answer: D Explanation: The Confusion Assessment Method (CAM) is a tool the nurse can use to differentiate between delirium and dementia. It consists of two parts; the first part screens for cognitive impairment and the second part screens for reversible confusion. Although it is effective in differentiating between delirium and dementia, it does not measure the severity of the client's delirium and it does not screen for depression.
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.
Answer: D, E Explanation: In Alzheimer disease, the neuronal cells die in a characteristic order, beginning with neurons in the limbic system, including the hippocampus. There are two basic types of AD: familial and sporadic. Familial AD (eFAD) has a strong inherited component and is also called early-onset AD because it usually manifests before age 65. Sporadic AD shows no clear pattern of inheritance, although genetic factors may be involved. Because it typically develops after age 65, sporadic AD is sometimes referred to as late-onset AD. Damage to the limbic system from AD results in memory loss and emotional problems.