cognitive disorder practice questions
A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response?
"I don't see any bugs, but I can tell you are frightened. I will stay with you."
A older patient diagnosed with severe, late-stage dementia no longer recognizes family members. The family asks how long it will be before this patient recognizes them when they visit. What is the nurse's best reply?
"It is disappointing when someone you love no longer recognizes you."
An elderly patient is admitted with delirium secondary to a urinary tract infection. The family asks whether the patient will ever recover. Select the nurse's best response.
"The confusion will probably get better as we treat the infection."
8 yr old with basilar skull fx.; Which order should the nurse question and call the HCP 1. Suction as needed 2. daily wt. 3. clean liquids 4. maintain patent IV line
1 This is contraindicated in this pt, the catheter could enter the brain through the fx; increasing the risk of secondary infection
12. A patient with AD in a long-term care facility is wandering the halls very agitated, asking for her "mommy" and crying. What is the best response by the nurse? a. Ask the patient, "Why are you behaving this way?" b. Tell the patient, "Let's go get a snack in the kitchen." c. Ask the patient, "Wouldn't you like to lie down now?" d. Tell the patient, "Just take some deep breaths and calm down."
12. b. Patients with moderate to severe AD frequently become agitated but because their short-term memory loss is so pronounced, distraction is a very good way to calm them. "Why" questions are upsetting to them because they don't know the answer and they cannot respond to normal relaxation techniques.
13. The sister of a patient with AD asks the nurse whether prevention of the disease is possible. In responding, the nurse explains that there is no known way to prevent AD but there are ways to keep the brain healthy. What is included in the ways to keep the brain healthy (select all that apply)? a. Avoid trauma to the brain. b. Recognize and treat depression early. c. Avoid social gatherings to avoid infections. d. Do not overtax the brain by trying to learn new skills. e. Daily wine intake will increase circulation to the brain. f. Exercise regularly to decrease the risk for cognitive decline
13. a, b, f. Avoiding trauma to the brain, treating depression early, and exercising regularly can maintain cognitive function. Staying socially active, avoiding intake of harmful substances, and challenging the brain to keep its connections active and create new ones also help to keep the brain healthy.
What interventions should be done if a kid has a seizure? SELECT ALL 1. time it 2. restrain the kid 3. place in prone position 4. move furniture away from kid 5. stay with the kid 6. insert tongue blade
1,4,5
10. The patient is receiving donepezil (Aricept), lorazepam (Ativan), risperidone (Risperdal), and sertraline (Zoloft) for the management of AD. What benzodiazepine medication is being used to help manage this patient's behavior? a. Sertraline (Zoloft) b. Donepezil (Aricept) c. Lorazepam (Ativan) d. Risperidone (Risperdal)
10. c. Lorazepam (Ativan) is a benzodiazepine used to manage behavior with AD. Sertraline (Zoloft) is a selective serotonin reuptake inhibitor used to treat depression. Donepzil (Aricept) is a cholinesterase inhibitor used for decreased memory and cognition. Risperidone (Risperdal) is an antipsychotic used for behavior management.
11. What N-methyl-d-aspartate (NMDA) receptor antagonist is frequently used for a patient with AD who is experiencing decreased memory and cognition? a. Trazodone (Desyrel) b. Olanzapine (Zyprexa) c. Rivastigmine (Exelon) d. Memantine (Namenda)
11. d. Memantine (Namenda) is the N-methyl-d-aspartate (NMDA) receptor antagonist frequently used for AD patients with decreased memory and cognition. Trazodone (Desyrel) is an atypical antidepressant that may help with sleep problems. Olanzapine (Zyprexa) is an antipsychotic medication used for behavior management. Rivastigmine (Exelon) is a cholinesterase inhibitor used for decreased memory and cognition.
14. The son of a patient with early-onset AD asks if he will get AD. What should the nurse tell this man about the genetics of AD? a. The risk of early-onset AD for the children of parents with it is about 50%. b. Women get AD more often than men do, so his chances of getting AD are slim. c. The blood test for the ApoE gene to identify this type of AD can predict who will develop it. d. This type of AD is not as complex as regular AD, so he does not need to worry about getting AD.
14. a. The risk of early-onset AD for the children of parents with it is 50%. Women do get AD more often than men but that is more likely related to women living longer than men than to the type of AD. ApoE gene testing is used for research with late-onset AD but does not predict who will develop the disease. Late-onset AD is more genetically complex than early-onset AD and is more common in those over age 60 but because his parent has early-onset AD he is at a 50% risk of getting it.
15. A patient with moderate AD has a nursing diagnosis of impaired memory related to effects of dementia. What is an appropriate nursing intervention for this patient? a. Post clocks and calendars in the patient's environment. b. Establish and consistently follow a daily schedule with the patient. c. Monitor the patient's activities to maintain a safe patient environment. d. Stimulate thought processes by asking the patient questions about recent activities
15. b. Adhering to a regular, consistent daily schedule helps the patient to avoid confusion and anxiety and is important both during hospitalization and at home. Clocks and calendars may be useful in early AD but they have little meaning to a patient as the disease progresses. Questioning the patient about activities and events they cannot remember is threatening and may cause severe anxiety. Maintaining a safe environment for the patient is important but does not change the disturbed thought processes.
17. The wife of a man with moderate AD has a nursing diagnosis of social isolation related to diminishing social relationships and behavioral problems of the patient with AD. What is a nursing intervention that would be appropriate to provide respite care and allow the wife to have satisfactory contact with significant others? a. Help the wife to arrange for adult day care for the patient. b. Encourage permanent placement of the patient in the Alzheimer's unit of a long-term care facility. c. Refer the wife to a home health agency to arrange daily home nursing visits to assist with the patient's care. d. Arrange for hospitalization of the patient for 3 or 4 days so that the wife can visit out-of-town friends and relatives.
17. a. Adult day care is an option to provide respite for caregivers and a protective environment for the patient during the early and middle stages of AD. There are also in-home respite care providers. The respite from the demands of care allows the caregiver to maintain social contacts, perform normal tasks of living, and be more responsive to the patient's needs. Visits by home health nurses involve the caregiver and cannot provide adequate respite. Institutional placement is not always an acceptable option at earlier stages of AD, nor is hospitalization available for respite care.
9. What is one focus of collaborative care of patients with AD? a. Replacement of deficient acetylcholine in the brain b. Drug therapy for cognitive problems and undesirable behaviors c. The use of memory-enhancing techniques to delay disease progression d. Prevention of other chronic diseases that hasten the progression of AD
9. b. Because there is no cure for AD, collaborative management is aimed at controlling the decline in cognition, controlling the undesirable manifestations that the patient may exhibit, and providing support for the family caregiver. Anticholinesterase agents help to increase acetylcholine (ACh) in the brain but a variety of other drugs are also used to control behavior. Memoryenhancing techniques have little or no effect in patients with AD, especially as the disease progresses. Patients with AD have limited ability to communicate health symptoms and problems, leading to a lack of professional attention for acute and other chronic illnesses.
The nurse is caring for a pt with hydrocephalus that is scheduled for surgery. What is the priority intervention in the preop period? 1. test urine for protein 2. reposition the infant frequently 3. provide a stimulating environment 4. Bp q 15 minutes
2 the head should be reposition so they do not get ulcers and sores on their head
2. Which statement accurately describes dementia? a. Overproduction of β-amyloid protein causes all dementias. b. Dementia resulting from neurodegenerative causes can be prevented. c. Dementia caused by hepatic or renal encephalopathy cannot be reversed. d. Vascular dementia can be diagnosed by brain lesions identified with neuroimaging.
2. d. The diagnosis of vascular dementia can be aided by neuroimaging studies showing vascular brain lesions along with exclusion of other causes of dementia. Overproduction of β-amyloid protein contributes to Alzheimer's disease (AD). Vascular dementia can be prevented or slowed by treating underlying diseases (e.g., diabetes mellitus, cardiovascular disease). Dementia caused by hepatic or renal encephalopathy potentially can be reversed.
23. When caring for a patient in the severe stage of AD, what diversion or distraction activities would be appropriate? a. Watching TV b. Playing games c. Books to read d. Mobiles or dangling ribbons
23. d. In the severe stage of AD, the patient is at a developmental level of 15 months or less; therefore appropriate distractions would be infant toys. Watching TV and playing games are more appropriate in the mild stage. Books to read would need to be at developmentally appropriate levels to be used as a diversion.
3. A patient with Alzheimer's disease (AD) dementia has manifestations of depression. The nurse knows that treatment of the patient with antidepressants will most likely do what? a. Improve cognitive function b. Not alter the course of either condition c. Cause interactions with the drugs used to treat the dementia d. Be contraindicated because of the central nervous system (CNS)-depressant effect of antidepressants
3. a. Depression is often associated with AD, especially early in the disease when the patient has awareness of the diagnosis and the progression of the disease. When dementia and depression occur together, intellectual deterioration may be more extreme. Depression is treatable and use of antidepressants often improves cognitive function.
The nurse notes a kid has a positive Kernig's sign. Which observation is characteristic of this sign? 1. The kid c/o muscle and joint pain 2. petechial and purpuric rashes are noted on the child's trunk 3. neck flexion causes adduction and flexion movements of the lower extremities 4. The child in not able to extend the leg when the thigh is flexed anteriorly at the hip
4
7. The wife of a patient who is manifesting deterioration in memory asks the nurse whether her husband has AD. The nurse explains that a diagnosis of AD is usually made when what happens? a. A urine test indicates elevated levels of isoprostanes b. All other possible causes of dementia have been eliminated c. Blood analysis reveals increased amounts of β-amyloid protein d. A computed tomography (CT) scan of the brain indicates brain atrophy
7. b. The only definitive diagnosis of AD can be made on examination of brain tissue during an autopsy but a clinical diagnosis is made when all other possible causes of dementia have been eliminated. Patients with AD may have β-amyloid proteins in the blood, brain atrophy, or isoprostanes in the urine but these findings are not exclusive to those with AD.
The nurse is reviewing notes on kid with increased ICP, What are characteristics of decerebrate posturing? 1. flaccid paralysis 2. adduction of the arms at the shoulders 3. rigid extension and pronation of the arms and legs 4. abnormal flexion of the upper extremities and extension of the lower ones
3 Extension posturing is characterized by the rigid extension and pronation of the arms and legs
A LP is done on a kid who is suspected of having bacterial meningitis and CSF is obtained. Which result would be positive for meningitis? 1. Clear CNS, decreased pressure, & elevated protein level 2. Clear CNS, ^protein, decreased glucose level 3. Cloudy CNS, ^protein, decreased glucose 4. Cloudy CNS, decreased protein and glucose
3 meningitis = elevated pressure, cloudy CNS, elevated leukocyte and protein and decreased glucose
A 5 year old arrives at ER and mom states he fell off bunk bed. What is a late sign of increased ICP? 1. Nausea 2. irritability 3. HA 4. bradycardia
4 Late signs are *significant level of consciousness *bradycardia *decreases motor and sensory responses *alterations in pupil sizes and reactivity *posturing *Cheyne- stokes respirations and coma
What precautionary intervention should be in place for a pt. with bacterial meningitis? 1. maintain enteric precautions 2. maintain neutropenic precautions 3. no precautions are required as long as an ATB has been started 4. maintain resp. isolation precautions for at least 24 hrs after the initiation of ATB
4 A major priority with meningitis is to have ATB started stat, the kid is also placed in resp. isolation for at least 24 hrs while cultures are collected and the ABT is having an effect
The parents of a kid recently dx. with CP asks the nurse about the disorder. The nurse bases the response on the understanding that CP is what type of condition? 1. An infectious disease of the CNS 2. An inflammation of the brain as a result of a viral illness 3. A congenital condition that results in moderate to severe retardation 4. A chronic disability characterized by impaired muscle movement and posture
4 Cerebral palsy is a chronic disability characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system *meningitis is an infection process of the CNS *encephalitis is an inflammation d/t virus *DS is a congenital condition
What should be bedside in a patient with tonic clonic seizures? 1. emergency cart 2. trach set 3. padded tongue blade 4. suctioning and O2
4 Suctioning and O2 * a trach set is not done at bedside, and an emergency cart would not be left in a room
A kids is Dx. with Reye's syndrome. Which intervention should be added to the plan? 1. assess hearing loss 2. monitor urine output 3. change position q 2 hr 4. provide quiet room with dim lighting
4. Reye's is an acute encephalopathy that follows a viral illness and is characterized by cerebral edema and fatty changes in the liver * care is directed towards managing cerebral edema; decreasing stimuli and dimming lights decreases the stress on the cerebral tissue and neuron responses *position with HOB elevated to decrease the progression of edema and promote drainage
4. For what purpose would the nurse use the Mini-Mental State Examination to evaluate a patient with cognitive impairment? a. It is a good tool to determine the etiology of dementia. b. It is a good tool to evaluate mood and thought processes. c. It can help to document the degree of cognitive impairment in delirium and dementia. d. It is useful for initial evaluation of mental status but additional tools are needed to evaluate changes in cognition over time.
4. c. The Mini-Mental State Examination is a tool to document the degree of cognitive impairment and it can be used to determine a baseline from which changes over time can be evaluated. It does not evaluate mood or thought processes but can detect dementia and delirium and differentiate these from psychiatric mental illness. It cannot help to determine etiology.
5. During assessment of a patient with dementia, the nurse determines that the condition is potentially reversible when finding out what about the patient? a. Has long-standing abuse of alcohol b. Has a history of Parkinson's disease c. Recently developed symptoms of hypothyroidism d. Was infected with human immunodeficiency virus (HIV) 10 years ago
5. c. Hypothyroidism can cause dementia but it is a treatable condition if it has not been long standing. The other conditions are causes of irreversible dementia.
6. The husband of a patient is complaining that his wife's memory has been decreasing lately. When asked for examples of her memory loss, the husband says that she is forgetting the neighbors' names and forgot their granddaughter's birthday. What kind of loss does the nurse recognize this to be? a. Delirium b. Memory loss in AD c. Normal forgetfulness d. Memory loss in mild cognitive impairment
6. d. In mild cognitive impairment people frequently forget people's names and begin to forget important events. Delirium changes usually occur abruptly. In Alzheimer's disease the patient may not remember knowing a person and loses the sense of time and which day it is. Normal forgetfulness includes momentarily forgetting names and occasionally forgetting to run an errand.
An elderly person presents with symptoms of delirium. The family reports, "Everything was fine until yesterday." What is the most important assessment information for the nurse to gather?
A list of all medications the person currently takes
2. A husband has agreed to admit his spouse, diagnosed with Alzheimer's disease (AD), to a long-term care facility. He is expressing feelings of guilt and symptoms of depression. Which appropriate nursing diagnosis and subsequent intervention would the nurse document? 1. Dysfunctional grieving; AD support group 2. Altered thought process; AD support group 3. Major depressive episode; psychiatric referral 4. Caregiver role strain; psychiatric referral
ANS: 1 Rationale: The most appropriate nursing diagnosis and intervention for the husband is dysfunctional grieving; AD support group. Clients with AD are often at risk for trauma and have significant self-care deficits that require more care than a spouse may be able to provide.
7. A client diagnosed recently with AD is prescribed donepezil (Aricept). The client's spouse inquires, "How does this work? Will this cure him?" Which is the appropriate nursing response? 1. "This medication delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the disease." 2. "This medication encourages production of acetylcholine, a chemical in the brain necessary for memory processes. It delays the progression of the disease." 3. "This medication delays the destruction of dopamine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the disease." 4. "This medication encourages production of dopamine, a chemical in the brain necessary for memory processes. It delays the progression of the disease."
ANS: 1 Rationale: The most appropriate response by the nurse is to explain that donepezil delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the AD. Some side effects include dizziness, headache, gastrointestinal upset, and elevated transaminase.
1. A geriatric nurse is teaching the client's family about the possible cause of delirium. Which statement by the nurse is most accurate? 1. "Taking multiple medications may lead to adverse interactions or toxicity." 2. "Age-related cognitive changes may lead to alterations in mental status." 3. "Lack of rigorous exercise may lead to decreased cerebral blood flow." 4. "Decreased social interaction may lead to profound isolation and psychosis."
ANS: 1 Rationale: The nurse should identify that taking multiple medications that may lead to adverse reactions or toxicity is a risk factor for the development of delirium in older adults. Symptoms of delirium include difficulty sustaining and shifting attention. The client with delirium is disoriented to time and place and may also have impaired memory.
18. Which of the following conditions have been known to precipitate delirium in some individuals? (Select all that apply.) 1. Febrile illness 2. Seizures 3. Migraine headaches 4. Herniated brain stem 5. Temporomandibular joint syndrome
ANS: 1, 2, 3 Rationale: Delirium most commonly occurs in individuals with serious medical, surgical, or neurological conditions. Some examples of conditions that have been known to precipitate delirium in some individuals include the following: systemic infections; febrile illness; metabolic disorders, such as hypoxia, hypercarbia, or hypoglycemia; hepatic encephalopathy; head trauma; seizures; migraine headaches; brain abscess; stroke; postoperative states; and electrolyte imbalance. A herniated brain stem would most likely result in death, not delirium. Temporomandibular joint syndrome is marked by limited movement of the joint during chewing, not delirium.
19. Which of the following medications that have been known to precipitate delirium? (Select all that apply.) 1. Antineoplastic agents 2. H2-receptor antagonists 3. Antihypertensives 4. Corticosteroids 5. Lipid-lowering agents
ANS: 1, 2, 3, 4 Rationale: Medications that have been known to precipitate delirium include anticholinergics, antihypertensives, corticosteroids, anticonvulsants, cardiac glycosides, analgesics, anesthetics, antineoplastic agents, antiparkinson drugs, H2-receptor antagonists (e.g., cimetidine), and others. There have been no reports of delirium ascribed to the use of lipid-lowering agents.
17. Which statement accurately differentiates NCD from pseudodementia (depression)? 1. NCD has a rapid onset, whereas pseudodementia does not. 2. NCD symptoms include disorientation to time and place, and pseudodementia does not. 3. NCD symptoms improve as the day progresses, but symptoms of pseudodementia worsen. 4. NCD causes decreased appetite, whereas pseudodementia does not.
ANS: 2 Rationale: NCD has a slow progression of symptoms, whereas pseudodementia has a rapid progression of symptoms. NCD symptoms include disorientation to time and place, and pseudodementia does not. NCD symptoms' severity worsens as the day progresses, whereas in pseudodementia, symptoms improve as the day progresses. In NCD the appetite remains unchanged. whereas in pseudodementia, the appetite diminishes. Multiple Response
13. A client with a history of cerebrovascular accident (CVA) is brought to an emergency department experiencing memory problems, confusion, and disorientation. Based on this client's assessment data, which diagnosis would the nurse expect the physician to assign? 1. Delirium due to adverse effects of cardiac medications 2. Vascular neurocognitive disorder 3. Altered thought processes 4. Alzheimer's disease
ANS: 2 Rationale: The nurse should expect that the client will be diagnosed with vascular NCD, which is caused by significant cerebrovascular disease. Vascular NCD often has an abrupt onset. Progression of this disease often occurs in a fluctuating pattern.
12. A client diagnosed with major NCD is exhibiting behavioral problems on a daily basis. At change of shift, the client's behavior escalates from pacing to screaming and flailing. Which action should be a nursing priority? 1. Consult the psychologist regarding behavior-modification techniques. 2. Medicate the client with prn antianxiety medications. 3. Assess environmental triggers and potential unmet needs. 4. Anticipate the behavior and restrain when pacing begins.
ANS: 2 Rationale: The priority nursing action is to first medicate the client to avoid injury to self or others. It is important to assess environmental triggers and potential unmet needs in order to address these problems in the future, but interventions to ensure safety must take priority. Because of the cognitive decline experienced in clients diagnosed with this disorder, communication skills and orientation may limit assessment and teaching interventions.
5. A client is diagnosed in stage seven of AD. To address the client's symptoms, which nursing intervention should take priority? 1. Improve cognitive status by encouraging involvement in social activities. 2. Decrease social isolation by providing group therapies. 3. Promote dignity by providing comfort, safety, and self-care measures. 4. Facilitate communication by providing assistive devices.
ANS: 3 Rationale: The most appropriate intervention in the seventh stage of AD is to promote the client's dignity by providing comfort, safety, and self-care measures. Stage is characterized by severe cognitive decline in which the client is unable to recognize family members and is most commonly bedfast and aphasic.
9. A client diagnosed with AD exhibits progressive memory loss, diminished cognitive functioning, and verbal aggression upon experiencing frustration. Which nursing intervention is most appropriate? 1. Organize a group activity to present reality. 2. Minimize environmental lighting. 3. Schedule structured daily routines. 4. Explain the consequences for aggressive behaviors.
ANS: 3 Rationale: The most appropriate nursing intervention for this client is to schedule structured daily routines. A structured routine will reduce frustration and thereby reduce verbal aggression.
8. Which symptom should a nurse identify that differentiates clients diagnosed with NCDs from clients diagnosed with mood disorders? 1. Altered sleep 2. Altered concentration 3. Impaired memory 4. Impaired psychomotor activity
ANS: 3 Rationale: The nurse should identify that impaired memory is a symptom that occurs in NCD and not in mood disorders. Neurocognitive disorder is classified in the DSM-5 as either mild or major, with the distinction primarily being one of severity of symptomatology.
10. After one week of continuous mental confusion, an older African American client is admitted with a preliminary diagnosis of AD. What should cause the nurse to question this diagnosis? 1. AD does not typically occur in African American clients. 2. The symptoms presented are more indicative of Parkinsonism. 3. AD does not develop suddenly. 4. There has been no T3- or T4-level evaluation ordered.
ANS: 3 Rationale: The nurse should recognize that AD does not develop suddenly and should question this diagnosis. The onset of AD symptoms is slow and insidious. The disease is generally progressive and deteriorating.
15. A client diagnosed with NCD is disoriented and ataxic and wanders. Which is the priority nursing diagnosis? 1. Disturbed thought processes 2. Self-care deficit 3. Risk for injury 4. Altered health-care maintenance
ANS: 3 Rationale: The priority nursing diagnosis for this client is risk for injury. The client who is ataxic suffers from motor coordination deficits and is at an increased risk for falls. Clients that wander are at a higher risk for injury.
16. Which statement accurately differentiates mild NCD from major NCD? 1. Major NCD involves disorientation that develops suddenly, whereas mild NCD develops more slowly. 2. Major NCD involves impairment of abstract thinking and judgment, whereas mild NCD does not. 3. Major NCD criteria requires substantial cognitive decline from a previous level of performance, and mild NCD requires modest decline. 4. Major NCD criteria requires decline from a previous level of performance in three of the listed domains, and mild NCD requires only one.
ANS: 3 Rationale: The progression of the disorder is not a criterion for determining the severity of an NCD. Abstract thinking and judgment can be affected in both mild NCD and major NCD. Major NCD criteria requires substantial cognitive decline, and mild NCD requires modest decline. Both major and mild NCD classifications require decline from a previous level of performance in only one of the listed domains.
14. An older client has recently moved to a nursing home. The client has trouble concentrating and socially isolates. A physician believes the client would benefit from medication therapy. Which medication should the nurse expect the physician to prescribe? 1. Haloperidol (Haldol) 2. Donepezil (Aricept) 3. Diazepam (Valium) 4. Sertraline (Zoloft)
ANS: 4 Rationale: The nurse should expect the physician to prescribe sertraline to improve the client's social functioning and concentration levels. Sertraline is an selective serotonin reuptake inhibitor (SSRI) antidepressant. Depression is the most common mental illness in older adults and is often misdiagnosed as a neurocognitive disorder.
3. A client diagnosed with vascular neurocognitive disorder (NCD) is discharged to home under the care of his wife. Which information should cause the nurse to question the client's safety? 1. His wife works from home in telecommunication. 2. The client has worked the nightshift his entire career. 3. His wife has minimal family support. 4. The client smokes one pack of cigarettes per day.
ANS: 4 Rationale: The nurse should question the client's safety at home if the client smokes cigarettes. Vascular NCD is a clinical syndrome of NCD due to significant cerebrovascular disease. The cause of vascular NCD is related to an interruption of blood flow to the brain. Hypertension is a significant factor in the etiology.
4. A client diagnosed with AD can no longer ambulate, does not recognize family members, and communicates with agitated behaviors and incoherent verbalizations. The nurse recognizes these symptoms as indicative of which stage of the illness? 1. Stage 4: Mild-to-Moderate Cognitive Decline 2. Stage 5. Moderate Cognitive Decline 3. Stage 6. Moderate-to-Severe Cognitive Decline 4. Stage 7. Severe Cognitive Decline
ANS: 4 Rationale: The nurse should recognize that a client exhibiting these symptoms is in the severe cognitive decline, seventh stage, of AD.
11. A client diagnosed with AD has impairments of memory and judgment and is incapable of performing activities of daily living. Which nursing intervention should take priority? 1. Present evidence of objective reality to improve cognition. 2. Design a bulletin board to represent the current season. 3. Label the client's room with name and number. 4. Assist with bathing and toileting.
ANS: 4 Rationale: The priority nursing intervention for this client is to assist with bathing and toileting. A client who is incapable of performing activities of daily living requires assistance in these areas to ensure health and safety.
6. Which is the reason for the proliferation of the diagnosis of NCDs? 1. Increased numbers of neurotransmitters has been implicated in the proliferation of NCD. 2. Similar symptoms of NCD and depression lead to misdiagnoses, increasing numbers of NCD. 3. Societal stress contributes to the increase in this diagnosis. 4. More people now survive into the high-risk period for neurocognitive disorders.
ANS: 4 Rationale: The proliferation of NCD has occurred because more people now survive into the high-risk period for neurocognitive disorder, which is middle age and beyond..
A patient diagnosed with Alzheimer's disease calls the fire department saying, "My smoke detectors are going off." Firefighters investigate and discover that the patient misinterpreted the telephone ringing. Which problem is this patient experiencing?
Agnosia
An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident?
Agnosia
Consider these diagnostic findings: apolipoprotein E (apoE) malfunction, neurofibrillary tangles, neuronal degeneration in the hippocampus, and brain atrophy. Which health problem corresponds to these diagnostic findings?
Alzheimer's disease
The nurse notes signs if uncreased ICP in a kid who has undergone insertion of a shunt to tx. hydrocephalus. What should the nurse do?
An early sign is a change in the level of consciousness, HA, N&V, diplopia or visual disturbances and seizures. *normally the DR. orders the kid to be kept flat to avoid rapid reduction of intracranial fluid. If increased ICP occurs the HOB should be elevated 15-30 degrees and enhance flow, surgeon notified STAT
A patient has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment?
Assist the patient to perform simple tasks by giving step-by-step directions.
What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations?
Careful observation and supervision
A nurse gives anticipatory guidance to the family of a patient diagnosed with stage 3, mild cognitive decline Alzheimer's disease. Which problem common to that stage should the nurse address?
Communication defecits
During morning care, a nurse asks a patient diagnosed with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response?
Confabulation
When administering a mental status examination to a patient, the nurse suspects depression when the patient responds with a. "I don't know." b. "Is that the right answer?" c. "Wait, let me think about that." d. "Who are those people over there?"
Correct Answer: A Rationale: Answers such as "I don't know" are more typical of depression. The response "Who are those people over there?" is more typical of the distraction seen in a patient with delirium. The remaining two answers are more typical of a patient with dementia.
The nurse has identified the nursing diagnosis of disturbed thought processes related to effects of dementia for a patient with late-stage Alzheimer's disease (AD). An appropriate intervention for this problem is to a. maintain a consistent daily routine for the patient's care. b. encourage the patient to discuss events from the past. c. reorient the patient to the date and time every few hours. d. provide the patient with current newspapers and magazines.
Correct Answer: A Rationale: Providing a consistent routine will decrease anxiety and confusion for the patient. In late-stage AD, the patient will not remember events from the past. Reorientation to time and place will not be helpful to the patient with late-stage AD. The patient with late-stage AD will not be able to read. Cognitive Level: Application Text Reference: p. 1571 Nursing Process: Planning NCLEX: Physiological Integrity
Risperidone (Risperdal) is prescribed for an outpatient with moderate Alzheimer's disease (AD). Which information obtained by the nurse at the next clinic appointment indicates that the medication is effective? a. The patient has less agitation. b. The patient is dressed appropriately. c. The patient is able to swallow a pill. d. The patient's speech is clearer.
Correct Answer: A Rationale: Risperidone is an antipsychotic used to treat the agitation, aggression, and behavioral problems associated with AD. The other improvements might occur with cholinesterase inhibitors. Cognitive Level: Application Text Reference: p. 1568 Nursing Process: Evaluation NCLEX: Physiological Integrity
When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse include? a. Reminding the patient frequently about being in the hospital b. Placing suction at the bedside to decrease the risk for aspiration c. Providing complete personal hygiene care for the patient d. Repositioning the patient frequently to avoid skin breakdown
Correct Answer: A Rationale: The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility. Cognitive Level: Application Text Reference: p. 1563 Nursing Process: Planning NCLEX: Physiological Integrity
A long-term care patient with moderate dementia develops increased restlessness and agitation. The nurse's initial action should be to a. administer the PRN dose of lorazepam (Ativan). b. reorient the patient to time and place. c. assess the patient for anything that might be causing discomfort. d. have a nursing assistant stay with the patient to ensure safety.
Correct Answer: C Rationale: Increased motor activity in a patient with dementia is frequently the patient's only way of responding to factors like pain, so the nurse's initial action should be to assess the patient for any precipitating factors. Administration of sedative drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia. Assigning a nursing assistant to stay with the patient may also be necessary, but any physical changes that may be causing the agitation should be addressed first. Cognitive Level: Application Text Reference: p. 1573 Nursing Process: Implementation NCLEX: Physiological Integrity
A family member of a patient with possible Alzheimer's disease asks the nurse the purpose of the Mini-Mental State Examination (MMSE). Which response by the nurse is appropriate? a. The MMSE helps in establishing the diagnosis of Alzheimer's disease (AD). b. The MMSE is useful in determining the degree of mental impairment. c. The MMSE determines the choice of the most appropriate treatment. d. The MMSE aids in differentiating acute delirium from chronic dementia.
Correct Answer: B Rationale: The MMSE establishes the degree of mental impairment at the time it is given. It does not establish a diagnosis of AD but when given repeatedly over time may help to determine the progression of AD. The choice of treatment is made on the basis of multiple data, not just the MMSE. The MMSE may be abnormal with either delirium or dementia and is not useful in determining which condition the patient has. Cognitive Level: Application Text Reference: p. 1563 Nursing Process: Implementation NCLEX: Physiological Integrity
When teaching the spouse of a patient who is being evaluated for Alzheimer's disease (AD) about the disorder, the nurse explains that a. the most important risk factor for AD is a family history of the disorder. b. a diagnosis of AD can be made only when other causes of dementia have been ruled out. c. new drugs have been shown to reverse AD dramatically in some patients. d. the presence of brain atrophy detected by MRI confirms the diagnosis of AD in patients with dementia.
Correct Answer: B Rationale: The diagnosis of AD is one of exclusion. Age is the most important risk factor for development of AD. Drugs can slow the deterioration but do not dramatically reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in other diseases as well. Cognitive Level: Comprehension Text Reference: p. 1568 Nursing Process: Implementation NCLEX: Physiological Integrity
During the morning change-of-shift report at the long-term care facility, the nurse learns that the patient with dementia has had sundowning. Which nursing action should the nurse take while caring for the patient? a. Move the patient to a quieter room at night. b. Open the blinds in the patient's room and provide frequent activities. c. Have the patient take a brief mid-morning nap. d. Provide hourly orientation to time of day.
Correct Answer: B Rationale: The most likely cause of sundowning is a disruption in circadian rhythms and keeping the patient active and in daylight will help to reestablish a more normal circadian pattern. Moving the patient to a different room might increase confusion. Taking a nap will interfere with nighttime sleep. Hourly orientation will not be helpful in a patient with memory difficulties. Cognitive Level: Application Text Reference: p. 1573 Nursing Process: Implementation NCLEX: Safe and Effective Care Environment
To protect a patient from injury during an episode of delirium, the most appropriate action by the nurse is to a. have a close family member remain with the patient and provide reassurance. b. assign a staff member to stay with the patient and offer frequent reorientation. c. ask the health care provider about ordering an antipsychotic drug. d. secure the patient in bed with a soft chest restraint.
Correct Answer: B Rationale: The priority goal is to protect the patient from harm, and a staff member will be most experienced in providing safe care. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have multiple side effects. Restraints are sometimes used but tend to increase agitation and disorientation. Cognitive Level: Application Text Reference: p. 1577 Nursing Process: Implementation NCLEX: Physiological Integrity
Coexisting dementia and depression are identified in a patient with Parkinson's disease. The nurse anticipates that the greatest improvement in the patient's condition will occur with administration of a. antipsychotic drugs. b. anticholinergic agents. c. dopaminergic agents and antidepressant drugs. d. selective serotonin reuptake inhibitor (SSRI) agents.
Correct Answer: C Rationale: Parkinson's disease and depression are both potentially reversible conditions, and the patient's symptoms that are caused by these two conditions will improve with appropriate treatment. Anticholinergic agents are likely to worsen the patient's condition because they will block the effect of acetylcholine at the synaptic cleft. There is no indication that the patient needs an antipsychotic agent at this time. A selective serotonin reuptake inhibitor (SSRI) may be effective for the depression, but it does not address the patient's other conditions. Cognitive Level: Application Text Reference: p. 1563 Nursing Process: Planning NCLEX: Physiological Integrity
A 72-year-old patient hospitalized with pneumonia is disoriented and confused 2 days after admission. Which assessment information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia? a. The patient is disoriented to place and time but oriented to person. b. The patient has a history of increasing confusion over several years. c. The patient's speech is fragmented and incoherent. d. The patient was oriented and alert when admitted.
Correct Answer: D Rationale: The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia. Cognitive Level: Application Text Reference: p. 1562 Nursing Process: Assessment NCLEX: Physiological Integrity
3. When administering a mental status examination to a patient with delirium, the nurse should a. give the examination when the patient is well-rested. b. reorient the patient as needed during the examination. c. choose a place without distracting environmental stimuli. d. medicate the patient first to reduce anxiety.
Correct Answer: C Rationale: Because overstimulation by environmental factors can distract the patient from the task of answering the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient's delirium. Cognitive Level: Application Text Reference: pp. 1562, 1576-1577 Nursing Process: Implementation NCLEX: Physiological Integrity
A home-health patient with Alzheimer's disease (AD) and mild dementia has a new prescription for donepezil (Aricept). Which nursing action will be most effective in ensuring compliance with the medication? a. Setting the medications up weekly in a medication box b. Calling the patient daily with a reminder to take the medication c. Having the patient's spouse administer the medication d. Posting reminders to take the medications in the patient's house
Correct Answer: C Rationale: Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the Aricept. The other nursing actions will not be as effective in ensuring that the patient takes the medications. Cognitive Level: Application Text Reference: pp. 1563, 1567 Nursing Process: Implementation NCLEX: Physiological Integrity
When assessing a patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility, the nurse learns that the patient has had several episodes of wandering away from home. Which nursing action will the nurse include in the plan of care? a. Ask the patient why the wandering episodes have occurred. b. Reorient the patient to the new living situation several times daily. c. Place the patient in a room close to the nurses' station. d. Have the family bring in familiar items from the patient's home.
Correct Answer: C Rationale: Patients at risk for problems with safety require close supervision. Placing the patient near the nurse's station will allow nursing staff to observe the patient more closely. Use of "why" questions is frustrating for the patient with AD, who are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patient's short-term memory loss, reorientation will not help to prevent wandering behavior. Because the patient had wandering behavior at home, familiar objects will not prevent wandering. Cognitive Level: Application Text Reference: p. 1573 Nursing Process: Planning NCLEX: Safe and Effective Care Environment
A patient with Alzheimer's disease (AD) is hospitalized with a urinary tract infection. The spouse tells the nurse, "I am just exhausted from the constant care and worry. We don't have any children and we can't afford a nursing home. I don't know what to do." The most appropriate nursing diagnosis for the spouse is a. anxiety related to limited financial resources. b. ineffective health maintenance related to stress. c. caregiver role strain related to limited resources for caregiving. d. social isolation related to unrelieved caregiving responsibilities.
Correct Answer: C Rationale: The spouse's statements are most consistent with caregiver role strain. The other diagnoses each address one aspect of the spouse's problem, but caregiver-role strain related to limited resources for caregiving addresses all the information the nurse has about this situation. Cognitive Level: Application Text Reference: pp. 1574-1575 Nursing Process: Diagnosis NCLEX: Psychosocial Integrity
A 62-year-old patient is brought to the clinic by a family member who is concerned about the patient's increasing sleep disturbances and inability to solve common problems. To obtain information about the patient's current mental status, which question should the nurse ask the patient? a. "Where were you were born?" b. "Do have any feelings of sadness?" c. "What day of the week is it today?" d. "How positive is your self-image?"
Correct Answer: C Rationale: This question tests the patient's orientation to time, which is decreased in early Alzheimer's disease (AD) or dementia. Asking the patient about birthplace tests for remote memory, which is intact in the early stages. Questions about the patient's emotions and self-image are helpful in assessing emotional status, but they are not as helpful in assessing mental state. Cognitive Level: Application Text Reference: pp. 1564, 1567 Nursing Process: Assessment NCLEX: Physiological Integrity
A 71-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. variable ability to perform simple tasks. c. difficulty eating and swallowing. d. loss of recent and long-term memory.
Correct Answer: D Rationale: Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient's ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia. Cognitive Level: Application Text Reference: pp. 1562-1563 Nursing Process: Assessment NCLEX: Physiological Integrity
An older adult patient takes multiple medications daily. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of
Delerium
Consider these health problems: Lewy body disease, frontal-temporal lobar degeneration, and Huntington's disease. Which term unifies these problems?
Dementia
An older adult is prescribed digoxin (Lanoxin) and hydrochlorothiazide daily as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the patient's change in mental status?
Drug actions and interactions
A patient with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members?
Focus interaction on familiar topics.
Which assessment findings would the nurse expect in a patient experiencing delirium? Select all that apply
Impaired level of consciousness Disorientation to place and time Wandering attention
A patient with stage 3 Alzheimer's disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time?
Impaired memory
A high shrill cry in an infant can be a sign of what?
Increased ICP
An older adult with moderately severe dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient's family?
Label the bathroom door
What is the priority need for a patient with late-stage dementia?
Maintenance of nutrition and hydration
Which medication prescribed to patients diagnosed with Alzheimer's disease antagonizes N-Methyl-D-Aspartate (NMDA) channels rather than cholinesterase?
Memantine
An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police intervened, they found that this adult was wearing a heavy coat and hat, even though it was July. Which stage of Alzheimer's disease is evident?
Moderately severe cognitive decline
A nurse counsels the family of a patient diagnosed with Alzheimer's disease who lives at home and wanders at night. Which action is most important for the nurse to recommend to enhance safety?
Place locks at the tops of doors.
A patient diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this patient?
Provide a well-lit room without glare or shadows. Limit noise and stimulation.
A patient diagnosed with moderately severe Alzheimer's disease has a self-care deficit of dressing and grooming. Designate appropriate interventions to include in the patient's plan of care. Select all that apply
Provide clothing with elastic and hook-and-loop closures Label clothing with the patient's name and name of the item
A hospitalized patient diagnosed with delirium misinterprets reality, while a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? The patients will:
Remain safe in the environment.
What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?
Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment
Two patients in a residential care facility have dementia. One shouts to the other, "Move along, you're blocking the road." The other patient turns, shakes a fist, and shouts, "You're trying to steal my car." What is the nurse's best action?
Separate and distract the patients. Take one to the day room and the other to an activities area
Which assessment finding would be likely for a patient experiencing a hallucination? The patient:
States, "I feel bugs crawling on my legs and biting me."
A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs. Get them off!" Which problem is the patient experiencing?
Tactile Hallucinations
What is the earliest indication of an improvement or deterioration of the neurological condition?
The child's level of consciousness
Which nursing diagnoses are most applicable for a patient diagnosed with severe Alzheimer's disease? Select all that apply.
Urinary incontinence Distrurbed sleep pattern Risk for caregiver role strain
An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful?
Using the patient's glasses and hearing aids
What manifestations of cognitive impairment are primarily characteristic of delirium (select all that apply)? a. Reduced awareness b. Impaired judgments c. Words difficult to find d. Sleep/wake cycle reversed e. Distorted thinking and perception f. Insidious onset with prolonged duration
a, d, e. Manifestations of delirium include cognitive impairment with reduced awareness, reversed sleep/wake cycle, and distorted thinking and perception. The other options are characteristic of dementia.
The family caregiver for a patient with AD expresses an inability to make decisions, concentrate, or sleep. The nurse determines what about the caregiver? a. The caregiver is also developing signs of AD. b. The caregiver is manifesting symptoms of caregiver role strain. c. The caregiver needs a period of respite from care of the patient. d. The caregiver should ask other family members to participate in the patient's care.
b. Family caregiver role strain is characterized by such symptoms of stress as the inability to sleep, make decisions, or concentrate. It is frequently seen in family members who are responsible for the care of the patient with AD. Assessment of the caregiver may reveal a need for assistance to increase coping skills, effectively use community resources, or maintain social relationships. Eventually the demands on a caregiver exceed the resources and the person with AD may be placed in an institutional setting.
The newly admitted patient has moderate AD. What does the nurse know this patient will need help with? a. Eating b. Walking c. Dressing d. Self-care activities
c. In the moderate stage of AD, the patient may need help with getting dressed. In the severe stage, patients will be unable to dress or feed themselves and are usually incontinent.
Goals of care for an older adult patient diagnosed with delirium caused by fever and dehydration will focus on
returning to premorbid levels of function.