Schziophrenia, Bipolar Disorder, Alzheimers, Dementia, Delirium

In planning for the discharge of a client with a cognitive disorder, it is important to assess the client's caregiver support system. Which aspects are the most crucial to assess? Select all that apply. 1. Availability of resources for caregiver support. 2. Ability to provide the level of care and supervision needed by the client. 3. Willingness to transport the client to medical and psychiatric services. 4. Interest in engaging the cognitively disordered family member in reminiscence and games. 5. Willingness to install door alarms and make other safety changes. 6. Understanding the client's abilities and limitations.

12356 It is important for a caregiver to have support for herself as well as be able to provide adequate safety, supervision, and medical care to the client. The caregiver must also have realistic expectations of the client, given his abilities and limitations. Reminiscing and engaging the client in games is desirable but not crucial to care.

Transfer data for a client brought by ambulance to the hospital's psychiatric unit from a nursing home indicate that the client has become increasingly confused and disoriented. The client's behavior is found to be the result of cerebral arteriosclerosis. Which of the following behaviors of the nursing staff should positively influence the client's behavior? Select all that apply. 1. Limiting the client's choices. 2. Accepting the client as he is. 3. Allowing the client to do as he wishes. 4. Acting nonchalantly. 5. Explaining to the client what he needs to do step-by-step.

125 Confused clients need fewer choices, acceptance as a person, and step-by-step directions. Allowing the client to do as he wishes can lead to substandard care and the risk of harm. Acting nonchalantly conveys a lack of caring.

Which of the following is essential when caring for a client who is experiencing delirium? 1. Controlling behavioral symptoms with low-dose psychotropics. 2. Identifying the underlying causative condition or illness. 3. Manipulating the environment to increase orientation. 4. Decreasing or discontinuing all previously prescribed medications.

2 The most critical aspect when caring for the client with delirium is to institute measures to correct the underlying causative condition or illness. Controlling behavioral symptoms with low-dose psychotropics, manipulating the environment, and decreasing or discontinuing all medications may be dangerous to the client's health.

A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the client outcomes in the exhibit? Client Outcomes: 1. Maintains nutritional status 2. Interacts appropriately with peers 3. Remains free from injury 4. Sleeps 6 to 8 hours a night 1. 2, 1, 3, 4 2. 4, 1, 2, 3 3. 3, 1, 4, 2 4. 1, 4, 2, 3

3 The nurse should order client outcomes based on priority in the following order: Remains free of injury, maintains nutritional status, sleeps 6 to 8 hours a night, and interacts appropriately with peers. The nurse should prioritize the clients safety & physical health as most important.

The son of an elderly client who has cognitive impairments approaches the nurse and says, "I'm so upset. The physician says I have 4 days to decide on where my dad is going to live." The nurse responds to the son's concerns, gives him a list of types of living arrangements, and discusses the needs, abilities, and limitations of the client. The nurse should intervene further if the son makes which comment? 1. "Boy, I have a lot to think about before I see the social worker tomorrow." 2. "I think I can handle most of Dad's needs with the help of some home health care." 3. "I'm so afraid of making the wrong decision, but I can move him later if I need to." 4. "I want the social worker to make this decision so Dad won't blame me."

4 Expecting the social worker to make the decision indicates that the son is avoiding participating in decisions about his father. The other responses convey that the son understands the importance of a careful decision, the availability of resources, and the ability to make new plans if needed.

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.

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

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.

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.

When developing the plan of care for a client with Alzheimer's disease who is experiencing moderate impairment, which of the following types of care should the nurse expect to include? 1. Prompting and guiding activities of daily living. 2. Managing a medication schedule. 3. Constant supervision and total care. 4. Supervision of risky activities such as shaving.

1 Considerable assistance is associated with moderate impairment when the client cannot make decisions but can follow directions. Managing medications is needed even in mild impairment. Constant care is needed in the terminal phase, when the client cannot follow directions. Supervision of shaving is appropriate with mild impairment— that is, when the client still has motor function but lacks judgment about safety issues.

The nurse is attempting to draw blood from a woman with a diagnosis of delirium who was admitted last evening. The client yells out, "Stop; leave me alone. What are you trying to do to me? What's happening to me?" Which response by the nurse is most appropriate? 1. "The tests of your blood will help us figure out what is happening to you." 2. "Please hold still so I don't have to stick you a second time." 3. "After I get your blood, I'll get some medicine to help you calm down." 4. "I'll tell you everything after I get your blood tests to the laboratory."

1 Explaining why blood is being taken responds to the client's concerns or fears about what is happening to her. Threatening more pain or promising to explain later ignores or postpones meeting the client's need for information. The client's statements do not reflect loss of self control requiring medication intervention.

A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family members report that the client has experienced anorexia, insomnia, and recent job loss. Which nursing diagnosis should a nurse prioritize? 1. Risk for suicide R/T hopelessness 2. Anxiety: severe R/T hyperactivity 3. Imbalanced nutrition: less than body requirements R/T refusal to eat 4. Dysfunctional grieving R/T loss of employment

1 The priority nursing diagnosis for this client should be risk for suicide R/T hopelessness. The nurse should always prioritize client safety. This client is at risk for suicide because of his or her recent suicide attempt.

The client in the early stage of Alzheimer's disease and his adult son attend an appointment at the community mental health center. While conversing with the nurse, the son states, "I'm tired of hearing about how things were 30 years ago. Why does Dad always talk about the past?" The nurse should tell the son: 1. "Your dad lost his short-term memory, but he still has his long-term memory." 2. "You need to be more accepting of your dad's behavior." 3. "I want you to understand your dad's level of anxiety." 4. "Telling your dad that you are tired of hearing about the past will help him stop."

1 The son's statements regarding his father's recalling past events is typical for family members of clients in the early stage of Alzheimer's disease, when recent memory is impaired. Telling the son to be more accepting is critical and not an attempt to educate. Understanding the client's level of anxiety is unrelated to the memory loss of Alzheimer's disease. The client cannot stop reminiscing at will.

When helping the families of clients with Alzheimer's disease cope with vulgar or sexual behaviors, which of the following suggestions is most helpful? 1. Ignore the behaviors, but try to identify the underlying need for the behaviors. 2. Give feedback on the inappropriateness of the behaviors. 3. Employ anger management strategies. 4. Administer the prescribed risperidone (Risperdal).

1 The vulgar or sexual behaviors are commonly expressions of anger or more sensual needs that can be addressed directly. Therefore, the families should be encouraged to ignore the behaviors but attempt to identify their purpose. Then the purpose can be addressed, possibly leading to a decrease in the behaviors. Because of impaired cognitive function, the client is not likely to be able to process the inappropriateness of the behaviors if given feedback. Likewise, anger management strategies would be ineffective because the client would probably be unable to process the inappropriateness of the behaviors. Risperidone (Risperdal) may decrease agitation, but it does not improve social behaviors.

Nursing staff are trying to provide for the safety of an elderly female client with moderate dementia. She is wandering at night and has trouble keeping her balance. She has fallen twice but has had no resulting injuries. The nurse should: 1. Move the client to a room near the nurse's station and install a bed alarm. 2. Have the client sleep in a reclining chair across from the nurse's station. 3. Help the client to bed and raise all four bedrails. 4. Ask a family member to stay with the client at night.

1 Using a bed alarm enables the staff to respond immediately if the client tries to get out of bed. Sleeping in a chair at the nurse's station interferes with the client's restful sleep and privacy. Using all four bedrails is considered a restraint and unsafe practice. It is not appropriate to expect a family member to stay all night with the client.

The husband of a client with Alzheimer's disease that was diagnosed 6 years ago approaches the nurse and says, "I'm so excited that my wife is starting to use donepezil (Aricept) for her illness." The nurse should tell the husband: 1. The medication is effective mostly in the early stages of the illness. 2. The adverse effects of the drug are numerous. 3. The client will attain a functional level of that of 6 years ago. 4. Effectiveness in the terminal phase of the illness is scientifically proven.

1 When compared with other similar medications, donepezil (Aricept) has fewer adverse effects. Donepezil is effective primarily in the early stages of the disease. The drug helps to slow the progression of the disease if started in the early stages. After the client has been diagnosed for 6 years, improvement to the level seen 6 years ago is highly unlikely. Data are not available to support the drug's effectiveness for clients in the terminal phase of the disease.

An 83-year-old woman is admitted to the unit after being examined in the emergency department (ED) and diagnosed with delirium. After the admission interviews with the client and her grandson, the nurse explains that there will be more laboratory tests and X-rays done that day. The grandson says, "She has already been stuck several times and had a brain scan or something. Just give her some medicine and let her rest." The nurse should tell the grandson which of the following? Select all that apply. 1. "I agree she needs to rest, but there is no one specific medicine for your grandmother's condition." 2. "The doctor will look at the results of those tests in the ED and decide what other tests are needed." 3. "Delirium commonly results from underlying medical causes that we need to identify and correct." 4. "Tell me about your grandmother's behaviors and maybe I could figure out what medicine she needs." 5. "I'll ask the doctor to postpone more tests until tomorrow."

123 The client does need rest and it is true that there is no specific medicine for delirium, but it is crucial to identify and treat the underlying causes of delirium. Other tests will be based on the results of already completed tests. Although some medications may be prescribed to help the client with her behaviors, this is not the primary basis for medication orders. Because the underlying medical causes of delirium could be fatal, treatment must be initiated as soon as possible. It is not the nurse's role to determine medications for this client. Postponing tests until the next day is inappropriate.

A client has been in the critical care unit for 3 days following a severe myocardial infarction. Although he is medically stable, he has begun to have fluctuating episodes of consciousness, illogical thinking, and anxiety. He is picking at the air to "catch these baby angels flying around my head." While waiting for medical and psychiatric consults, the nurse must intervene with the client's needs. Which of the following needs have the highest priority? Select all that apply. 1. Decreasing as much "foreign" stimuli as possible. 2. Avoiding challenging the client's perceptions about "baby angels." 3. Orienting the client about his medical condition. 4. Gently presenting reality as needed. 5. Calling the client's family to report his onset of dementia.

124 The abnormal stimuli of the critical care unit can aggravate the symptoms of delirium. Arguing with hallucinations is inappropriate. When a client has illogical thinking, gently presenting reality is appropriate. Dementia is not the likely cause of the client's symptoms. The client is experiencing delirium, not dementia.

A client with early dementia exhibits disturbances in her mental awareness and orientation to reality. The nurse should expect to assess a loss of ability in which of the following other areas? 1. Speech. 2. Judgment. 3. Endurance. 4. Balance.

2 Clients with chronic cognitive disorders experience defects in memory orientation and intellectual functions, such as judgment and discrimination. Loss of other abilities, such as speech, endurance, and balance, is less typical.

A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following? 1. Administer PRN haloperidol (Haldol) to decrease the need to walk. 2. Assess the client's gait for steadiness. 3. Restrain the client in a geriatric chair. 4. Administer PRN lorazepam (Ativan) to provide sedation.

2 Elderly clients have increased risk for falls due to balance problems, medication use, and decreased eyesight. Haldol may cause extrapyramidal side effects (EPSE) which increase the risk for falls. The client is not agitated, so restraints are not indicated. Ativan may increase fall risk and cause paradoxical excitement.

The term motor apraxia relates to a decline in motor patterns essential for complex motor tasks. However, the client with severe dementia may be able to perform which of the following actions? 1. Balance a checkbook accurately. 2. Brush the teeth when handed a toothbrush. 3. Use confabulation when telling a story. 4. Find misplaced car keys.

2 Highly conditioned motor skills, such as brushing the teeth, may be retained by the client who has dementia and motor apraxia. Balancing a checkbook involves calculations, a complex skill that is lost with severe dementia Confabulation is fabrication of details to fill a memory gap. This is more common when the client is aware of a memory problem, not when dementia is severe. Finding keys is a memory factor, not a motor function.

A 69-year-old client is admitted and diagnosed with delirium. Later in the day, he tries to get out of the locked unit. He yells, "Unlock this door. I've got to go see my doctor. I just can't miss my monthly Friday appointment." Which of the following responses by the nurse is most appropriate? 1. "Please come away from the door. I'll show you your room." 2. "It's Tuesday and you are in the hospital. I'm Anne, a nurse." 3. "The door is locked to keep you from getting lost." 4. "I want you to come eat your lunch before you go the doctor."

2 Loss of orientation, especially for time and place, is common in delirium. The nurse should orient the client by telling him the time, date, place, and who the client is with. Taking the client to his room and telling him why the door is locked does not address his disorientation. Telling the client to eat before going to the doctor reinforces his disorientation.

A nurse on the Geropsychiatric unit receives a call from the son of a recently discharged client. He reports that his father just got a prescription for memantine (Namenda) to take "on top of his donepezil (Aricept)." The son then asks, "Why does he have to take extra medicines?" The nurse should tell the son: 1. "Maybe the Aricept alone isn't improving his dementia fast enough or well enough." 2. "Namenda and Aricept are commonly used together to slow the progression of dementia." 3. "Namenda is more effective than Aricept. Your father will be tapered off the Aricept." 4. "Aricept has a short half-life and Namenda has a long half-life. They work well together."

2 The two medicines are commonly given together. Neither medicine will improve dementia, but may slow the progression. Neither medicine is more effective than the other; they act differently in the brain. Both medicines have a half-life of 60 or more hours.

The family of a client, diagnosed with Alzheimer's disease, wants to keep the client at home. They say that they have the most difficulty in managing his wandering. The nurse should instruct the family to do which of the following? (Select all that apply). 1. Ask the physician for a sleeping medication. 2. Install motion and sound detectors. 3. Have a relative sit with the client all night. 4. Have the client wear a Medical Alert bracelet. 5. Install door alarms and high door locks.

245 Motion and sound detectors, a Medical Alert bracelet, and door alarms are all appropriate interventions for wandering. Sleep medications do not prevent wandering before and after the client is asleep and may have negative effects. Having a relative sit with the client is usually an unrealistic burden.

A client is experiencing agnosia as a result of vascular dementia. She is staring at dinner and utensils without trying to eat. Which intervention should the nurse attempt first? 1. Pick up the fork and feed the client slowly. 2. Say, "It's time for you to start eating your dinner." 3. Hand the fork to the client and say, "Use this fork to eat your green beans." 4. Save the client's dinner until her family comes in to feed her.

3 Agnosia is the lack of recognition of objects and their purpose. The nurse should inform the client about the fork and what to do with it. Feeding the client does not address the agnosia or give the client specific directions. It should only be attempted if identifying the fork and explaining what to do with it is ineffective. Waiting for the family to care for the client is not appropriate unless identifying the fork and explaining or feeding the client are not successful.

The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which of the following behaviors? 1. Sleep disturbances. 2. Concomitant depression. 3. Agitation and assaultiveness. 4. Confusion and withdrawal.

3 Antipsychotics are most effective with agitation and assaultiveness. Antipsychotics have little effect on sleep disturbances, concomitant depression, or confusion and withdrawal.

When communicating with the client who is experiencing dementia and exhibiting decreased attention and increased confusion, which of the following interventions should the nurse employ as the first step? 1. Using gentle touch to convey empathy. 2. Rephrasing questions the client doesn't understand. 3. Eliminating distracting stimuli such as turning off the television. 4. Asking the client to go for a walk while talking.

3 Competing and excessive stimuli lead to sensory overload and confusion. Therefore, the nurse should first eliminate any distracting stimuli. After this is accomplished, then using touch and rephrasing questions are appropriate. Going for a walk while talking has little benefit on attention and confusion.

Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium? 1. Explain the experience of having delirium. 2. Resume a normal sleep-wake cycle. 3. Regain orientation to time and place. 4. Establish normal bowel and bladder function.

3 In approximately 2 to 3 days, the client should be able to regain orientation and thus become oriented to time and place. Being able to explain the experience of having delirium is something that the client is expected to achieve later in the course of the illness, but ultimately before discharge. Resuming a normal sleep-wake cycle and establishing normal bowel and bladder function probably will take longer, depending on how long it takes to resolve the underlying condition.

The client with Alzheimer's disease may have delusions about being harmed by staff and others. When the client expresses fear of being killed by staff, which of the following responses is most appropriate? 1. "What makes you think we want to kill you?" 2. "We like you too much to want to kill you." 3. "You are in the hospital. We are nurses trying to help you." 4. "Oh, don't be so silly. No one wants to kill you here."

3 The nurse needs to present reality without arguing with the delusions. Therefore, stating that the client is in the hospital and the nurses are trying to help is most appropriate. The client doesn't recognize the delusion or why it exists. Telling the client that the staff likes him too much to want to kill him is inappropriate because the client believes the delusions and doesn't know that they are false beliefs. It also restates the word, kill, which may reinforce the client's delusions. Telling the client not to be silly is condescending and disparaging and therefore inappropriate.

The nurse observes a client in a group who is reminiscing about his past. Which effect should the nurse expect reminiscing to have on the client's functioning in the hospital? 1. Increase the client's confusion and disorientation. 2. Cause the client to become sad. 3. Decrease the client's feelings of isolation and loneliness. 4. Keep the client from participating in therapeutic activities.

3 Reminiscing can help reduce depression in an elderly client and lessens feelings of isolation and loneliness. Reminiscing encourages a focus on positive memories and accomplishments as well as shared memories with other clients. An increase in confusion and disorientation is most likely the result of other cognitive and situational factors, such as loss of short-term memory, not reminiscing. The client will not likely become sad because reminiscing helps the client connect with positive memories. Keeping the client from participating in therapeutic activities is less likely with reminiscing.

A client with dementia who prefers to stay in his room has been brought to the dayroom. After 10 minutes, the client becomes agitated and retreats to his room again. The nurse decides to assess the conditions in the dayroom. Which is the most likely occurrence that is disturbing to this client? 1. There is only one other client in the dayroom; the rest are in a group session in another room. 2. There are three staff members and one physician in the nurse's station working on charting. 3. A relaxation tape is playing in one corner of the room, and a television airing a special on crime is playing in the opposite corner. 4. A housekeeping staff member is washing off the countertops in the kitchen, which is on the far side of the dayroom.

3 The tape and television are competing, even conflicting, stimuli. Crime events portrayed on television could be misperceived as a real threat to the client. A low number of clients and the presence of a few staff members quietly working are less intense stimuli for the client and not likely to be disturbing.

While educating the daughter of a client with dementia about the illness, the daughter complains to the nurse that her mother distorts things. The nurse understands that the daughter needs further teaching about dementia when she makes which statement? 1. "I tell her reality, such as, 'That noise is the wind in the trees.'" 2. "I understand the misperceptions are part of the disease." 3. "I turn off the radio when we're in another room." 4. "I tell her she is wrong and then I tell her what's right."

4 Telling the client that she is wrong and then telling her what is right is argumentative and challenging. Arguing with or challenging distortions is least effective because it increases defensiveness. Telling the client about reality indicates awareness of the issues and is appropriate. Acknowledging that misperceptions are part of the disease indicates an understanding of the disease and an awareness of the issues. Turning off the radio helps to limit environmental stimuli and indicates an awareness of the issues.

A highly agitated client paces the unit & states, I could buy & sell this place. The clients mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this clients behavior? 1. Rates mood 8/10. Exhibiting looseness of association. Euphoric. 2. Mood euthymic. Exhibiting magical thinking. Restless. 3. Mood labile. Exhibiting delusions of reference. Hyperactive. 4. Agitated & pacing. Exhibiting grandiosity. Mood labile.

4 The nurse should document that this clients behavior is Agitated & pacing. Exhibiting grandiosity. Mood labile. The client is exhibiting mood swings from euphoria to irritability. Grandiosity refers to the attitude that ones abilities are better than everyone else's.

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.

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.

A patient experiencing mania has not eaten or slept for 3 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management

A Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patient's physiologic safety. Hyperactivity & poor judgment place the patient at risk for injury.

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?"

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.

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.

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

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 patient diagnosed with bipolar disorder is dressed in a red leotard & brightly colored scarves. The patient says, "I'll punch you, munch you, crunch you" while twirling & shadowboxing. Then the patient says gaily, Do you like my scarves? Here, they are my gift to you. How should the nurse document the patients mood? a. Labile and euphoric b. Irritable and belligerent c. Highly suspicious and arrogant d. Excessively happy and confident

A The patient has demonstrated angry behavior & pleasant, happy behavior within seconds of each other. Excessive happiness indicates euphoria. Mood swings are often rapid & seemingly without understandable reason in patients who are manic. These swings are documented as labile. Irritability, belligerence, excessive happiness & confidence are not entirely correct terms for the patient's mood. A high level of suspicion is not evident.

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.

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.

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

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 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

ABF 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 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

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.

This nursing diagnosis applies to a patient experiencing mania: Imbalanced nutrition: less than body requirements, related to insufficient caloric intake & hyperactivity as evidenced by 5-pound weight loss in 4 days. Select the most appropriate outcome. The patient will: a. ask staff for assistance with feeding within 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at mealtime within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while in the psychiatric unit.

B High-calorie, high-protein food supplements will provide the additional calories needed to offset the patients extreme hyperactivity. Sitting with others or asking for assistance does not mean the patient will eat or drink. Appropriate attire is unrelated to the nursing diagnosis.

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."

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.

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.

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.

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.

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

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

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.

A peer approaches you and shares her frustration with her older brother, who has had multiple hospitalizations with schizophrenia. "He used to show interest in me, but since his discharge 5 days ago, he just stares into space. I cannot get a reaction out of him." Which of the following statements impart accurate information? (Select all that apply.) A "Have you confronted him with this?" B "He may be demonstrating flattening of affect and anhedonia." C "He may have sedation or masked facial expressions from his medications." D "Maybe he's depressed about having a chronic illness." E "It's sad when a loved one does not have any feelings."

BCD

Which family member statements demonstrate recognition of the effects of social pressures associated with schizophrenia? (Select all that apply.) A "If my family member would just move in with me, it would be a lot easier for me to maintain my household and care for my children." B "It would be great if my family member could identify somebody to trust and believe when that person says, 'Your symptoms are worse. Let's go to the psychiatrist.'" C "I'll attend a support group, but I'm afraid my family member will not go...s/he would rather try to 'pass' as not mentally ill." D "I'm going to help my family member figure out what to tell other family members, friends, and business associates about why he's been on medical leave." E "I used to protect my family member from a lot of the interpersonal conflicts in the family, but we need to express our emotions more openly."

BCD

Which client statements demonstrate acknowledgment of the effects of psychological pressures associated with schizophrenia? (Select all that apply.) A "I just want to get back to what I was doing and put this whole episode behind me." B "If I can't stand the side effects, how will I ask my prescriber to change my medication?" C "I'm going to look for a job where I can use my college degree but have less day-to-day stress." D "Next month, my sister and I are going to write a grant proposal for a psychiatric day treatment/social center." E "I have designed a weekly schedule so that I can get tasks done and have planned time to relax."

BCE

The health care provider is trying to differentiate the diagnosis of the patient between dementia and dementia with Lewy bodies (DLB). What observations by the nurse support a diagnosis of DLB (select all that apply)? a. Tremors b. Fluctuating cognitive ability c. Disturbed behavior, sleep, and personality d. Symptoms of pneumonia, including congested lung sounds e. Bradykinesia, rigidity, and postural instability without tremor

BE Dementia with Lewy bodies (DLB) is diagnosed with dementia plus two of the following symptoms: (1) extrapyramidal signs such as bradykinesia, rigidity, and postural instability but not always a tremor, (2) fluctuating cognitive ability, and (3) hallucinations. The extrapyramidal signs plus tremors would more likely indicate Parkinson's disease. Disturbed behavior, sleep, personality, and eventually memory are characteristics of frontotemporal lobe degeneration (FTLD).

What should be included in the management of a patient with delirium? a. The use of restraints to protect the patient from injury b. The use of short-acting benzodiazepines to sedate the patient c. Identification and treatment of underlying causes when possible d. Administration of high doses of an antipsychotic drug such as haloperidol (Haldol)

C Care of the patient with delirium is focused on identifying and eliminating precipitating factors if possible. Treatment of underlying medical conditions, changing environmental conditions, and discontinuing medications that induce delirium are important. Drug therapy is reserved for those patients with severe agitation because the drugs themselves may worsen delirium.

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

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.

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.

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)

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.

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.

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

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

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.

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

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.

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.

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?"

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 patient diagnosed with bipolar disorder is hyperactive & manic after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate? a. Stop that! No one did anything to provoke an attack by you. b. If you do that one more time, you will be secluded immediately. c. Do not hit anyone. If you are unable to control yourself, we will help you. d. You know we will not let you hit anyone. Why do you continue this behavior?

C When the patient is unable to control her behavior & violates or threatens to violate the rights of others, limits must be set in an effort to de-escalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the patient & threaten the patient with seclusion as punishment. Asking why does not provide for environmental safety.

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

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.

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)

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.

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.

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

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.

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

LIST some NURSING DIAGNOSES for BIPOLAR DISORDER patients

- Risk for other-directed violence - Risk for injury - Imbalanced nutrition: less than body requirements - Ineffective coping - Noncompliance - Ineffective role performance - Self-care deficit - Chronic low self-esteem - Disturbed sleep pattern

List the CATEGORIES of BIPOLAR DISORDER according to DSM-V

- bipolar 1 - bipolar 2 - cyclothymic disorder - substance induced bipolar - bipolar induced by another medical condition - unclassified bipolar

The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the health care provider? 1. Paradoxical excitement. 2. Headache. 3. Slowing of reflexes. 4. Fatigue.

1 Although all of the side effects listed are possible with Ativan, paradoxical excitement is cause for immediate discontinuation of the medication. (Paradoxical excitement is the opposite reaction to Ativan than is expected.) The other side effects tend to be minor and usually are transient.

The client with dementia states to the nurse, "I know you. You're Margaret, the girl who lives down the street from me." Which of the following responses by the nurse is most therapeutic? 1. "Mrs. Jones, I'm Rachel, a nurse here at the hospital." 2. "Now Mrs. Jones, you know who I am." 3. "Mrs. Jones, I told you already, I'm Rachel and I don't live down the street." 4. "I think you forgot that I'm Rachel, Mrs. Jones."

1 Because of the client's short-term memory impairment, the nurse gently corrects the client by stating her name and who she is. This approach decreases anxiety, embarrassment, and shame and maintains the client's self-esteem. Telling the client that she knows who the nurse is or that she forgot can elicit feelings of embarrassment and shame. Saying, "I told you already" sounds condescending, as if blaming the client for not remembering.

Which of the following should the nurse expect to include as a priority in the plan of care for a client with delirium based on the nurse's understanding about the disturbances in orientation associated with this disorder? 1. Identifying self and making sure that the nurse has the client's attention. 2. Eliminating the client's napping in the daytime as much as possible. 3. Engaging the client in reminiscing with relatives or visitors. 4. Avoiding arguing with a suspicious client about his perceptions of reality.

1 Identifying oneself and making sure that the nurse has the client's attention addresses the difficulties with focusing, orientation, and maintaining attention. Eliminating daytime napping is unrealistic until the cause of the delirium is determined and the client's ability to focus and maintain attention improves. Engaging the client in reminiscing and avoiding arguing are also unrealistic at this time.

LIST the characteristics of a MANIC EPISODE.

1) Elated & Happy or Irritable & Angry 2) Racing thougts 3) Flight of Ideas 4) Increased talking 5) Pressurized speech 6) Increasing goal-directed activity 7) Grandiose plans 8) Unrealistic belief in one's ability 9) Risk taking 10) Impulsive, high-risk behaviors 11) Decreased sleep w/o fatigue

While assessing a client diagnosed with dementia, the nurse notes that her husband is concerned about what he should do when she uses vulgar language with him. The nurse should: 1. Tell her that she is very rude. 2. Ignore the vulgarity and distract her. 3. Tell her to stop swearing immediately. 4. Say nothing and leave the room.

2 Vulgar language is common in clients with dementia when they are having trouble communicating about a topic. Ignoring the vulgarity and distracting her is appropriate. Telling the client she is rude or to stop swearing will have no lasting effect and may cause agitation. Just leaving the room is abandonment that the client will not understand.

A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate (Lithobid) because of excessive weight gain. In order to increase adherence, which medication should a nurse anticipate that a physician may prescribe? 1. Sertraline (Zoloft) 2. Valproic acid (Depakote) 3. Trazodone (Desyrel) 4. Paroxetine (Paxil)

2 The nurse should anticipate that the physician may prescribe valproic acid in order to increase this clients medication adherence. Valproic acid is an anticonvulsant medication that can be used to treat bipolar disorder. One of the side effects of this medication is weight loss.

Which of the following is a priority to include in the plan of care for a client with Alzheimer's disease who is experiencing difficulty processing and completing complex tasks? 1. Repeating the directions until the client follows them. 2. Asking the client to do one step of the task at a time. 3. Demonstrating for the client how to do the task. 4. Maintaining routine and structure for the client.

2 Because the client is experiencing difficulty processing and completing complex tasks, the priority is to provide the client with only one step at a time, thereby breaking the task up into simple steps, ones that the client can process. Repeating the directions until the client follows them or demonstrating how to do the task is still too overwhelming to the client because of the multiple steps involved. Although maintaining structure and routine is important, it is unrelated to task completion.

A client diagnosed with bipolar disorder is distraught over insomnia experienced over the last 3 nights & a 12-pound weight loss over the past 2 weeks. Which should be this clients priority nursing diagnosis? 1. Knowledge deficit R/T bipolar disorder AEB concern about symptoms 2. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss 3. Risk for suicide R/T powerlessness AEB insomnia & anorexia 4. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights

2 The nurse should identify that the priority nursing diagnosis for this client is altered nutrition: less than body requirements R/T hyperactivity AEB weight loss. Because of the clients rapid weight loss, the nurse should prioritize interventions to ensure proper nutrition & physical health.

When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate? 1. Cancer of any kind. 2. Impaired hearing. 3. Prescription drug intoxication. 4. Heart failure.

3 Polypharmacy is much more common in the elderly. Drug interactions increase the incidence of intoxication from prescribed medications, especially with combinations of analgesics, digoxin, diuretics, and anticholinergics. With drug intoxication, the onset of the delirium typically is quick. Although cancer, impaired hearing, and heart failure could lead to delirium in the elderly, the onset would be more gradual.

During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply. 1. Ask the client's physician for a strong sleep medicine. 2. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. 3. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day. 4. Promote relaxation before bedtime with a warm bath or relaxing music. 5. Have the daughter encourage the use of caffeinated beverages during the day to keep her mother awake.

234 A set routine and brief exercises help decrease daytime sleeping. Decreasing caffeine and fluids and promoting relaxation at bedtime promote nighttime sleeping. A strong sleep medicine for an elderly client is contraindicated due to changes in metabolism, increased adverse effects, and the risk of falls. Using caffeinated beverages may stimulate metabolism but can also have long-lasting adverse effects and may prevent sleep at bedtime.

The nurse discusses the possibility of a client's attending day treatment for clients with early Alzheimer's disease. Which of the following is the best rationale for encouraging day treatment? 1. The client would have more structure to his day. 2. Staff are excellent in the treatment they offer clients. 3. The client would benefit from increased social interaction. 4. The family would have more time to engage in their daily activities.

3 The best rationale for day treatment for the client with Alzheimer's disease is the enhancement of social interactions. More daily structure, excellent staff, and allowing caregivers more time for themselves are all positive aspects, but they are less focused on the client's needs.

When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant? 1. Allow the client to go to bed four to five times during the day. 2. Test the cognitive functioning of the client several times a day. 3. Provide reality orientation even if the memory loss is severe. 4. Maintain consistency in environment, routine, and caregivers.

4 Change increases stress. Therefore, the most important and relevant suggestion is to maintain consistency in the client's environment, routine, and caregivers. Although rest periods are important, going to bed interferes with the sleep-wake cycle. Rest in a recliner chair is more useful. Testing cognitive functioning and reality orientation are not likely to be successful and may increase stress if memory loss is severe.

A family member asks you, "As both of my siblings have schizophrenia, why are my brother's symptoms so different from my sister's? He withdraws when there's a change in his environment or routine. She starts cursing and yelling about the Mafia and the CIA when I do something that's less than perfect." Based on your knowledge, your response should address: A The many differences in the presentation of schizophrenia. B The significance of paranoid content in the differential diagnosis of paranoid schizophrenia. C The typical progression of symptoms within an individual over time. D The effect of gender on clinical presentation in schizophrenia.

A

The nurse determines that the son of a client with Alzheimer's disease needs further education about the disease when he makes which of the following statements? 1. "I didn't realize the deterioration would be so incapacitating." 2. "The Alzheimer's support group has so much good information." 3. "I get tired of the same old stories, but I know it's important for Dad." 4. "I woke up this morning expecting that my old Dad would be back."

4 The statement about expecting that the old Dad would be back conveys a lack of acceptance of the irreversible nature of the disease. The statement about not realizing that the deterioration would be so incapacitating is based in reality. The statement about the Alzheimer's group is based in reality and demonstrates the son's involvement with managing the disease. Stating that reminiscing is important reflects a realistic interpretation on the son's part.

Delegation Decision: The RN in charge at a long-term care facility could delegate which activities to unlicensed assistive personnel (UAP) (select all that apply)? a. Assist the patient with eating. b. Provide personal hygiene and skin care. c. Check the environment for safety hazards. d. Assist the patient to the bathroom at regular intervals. e. Monitor for skin breakdown and swallowing difficulties.

ABD All caregivers are responsible for the patient's safety. Basic care activities, such as those associated with personal hygiene and activities of daily living (ADLs) can be delegated to unlicensed assistive personnel (UAP). The RN will perform ongoing assessments and develop and revise the plan of care as needed. The RN will assess the patient's safety risk factors, provide education, and make referrals. The licensed practical nurse (LPN) could check the patient's environment for potential safety hazards.

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

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.

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.

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.

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

A nurse is designing a relapse-prevention inpatient group for clients with schizophrenia. Which statement addresses a main category of nursing activities? A "We're going to discuss current events." B "Let's go around the room and have each person say something positive about our group." C "If you can increase your self-assessment skills, you'll be able to tell when you're getting more stressed." D "We will go around the room and each person will state a personal goal for today."

C

The client with schizophrenia is preparing for discharge. To minimize relapse, what is the most important feature of planning the client's aftercare? A Identification of two new ways to bolster self-esteem B Ensuring that the client lists three potential sources of social support C An accurate description of the medication regimen with a specific plan for obtaining refills D Identification of three new methods of spending leisure time

C

A person is directing traffic on a busy street while shouting & making obscene gestures at passing cars. The person has not slept or eaten for 3 days. What features of mania are evident? a. Increased muscle tension and anxiety b. Vegetative signs and poor grooming c. Poor judgment and hyperactivity d. Cognitive deficit and sad mood

C Hyperactivity (directing traffic) & poor judgment (putting self in a dangerous position) are characteristic of manic episodes. The distractors do not specifically apply to mania.

You have presented your client with written aftercare medication directions: "Take one capsule three times per day." Your client informs you that she has reviewed the material. Which response specifically addresses your concerns about adherence? A "If you forget one dose, you can double the next one." B "Do you understand everything?" C "This medication really works best if you take one capsule three times per day." D "What might get in the way of your taking your medications?"

D

You overhear a family member discussing medication adherence with your client. Which of the following statements do you want to encourage the family member to reiterate? A "Your children are getting tired of watching you get sick every time you stop your meds." B "If you stop taking your medication, I'll take custody of your children." C "You should let these health care providers get you well. Why do you fight that?" D "Your support group encourages you to make healthy choices. Taking your meds is a healthy thing you can do every day, just like brushing your teeth."

D

Which of the following client statements demonstrates the major symptoms of schizophrenia? A "I had too much to drink last night, started feeling all-powerful, and stupidly drove my truck into a tree." B "I've been depressed ever since our house was destroyed by fire." C "'A stitch in time saves nine' means that prevention is easier than fixing a real problem." D "You can read my mind. This light of mine will shine, fine; blinding world will end at nine."

D

While you are employed as a charge nurse on an inpatient psychiatric unit, you recognize that you are choosing to spend less time interacting with the clients with schizophrenia. Your first action is: A Discussing your observation with your clinical supervisor. B Requesting a transfer to another unit. C Forcing yourself to interact with the clients with schizophrenia. D Reflecting on your behavior.

D

A 68-year-old man is admitted to the emergency department with multiple blunt trauma following a one-vehicle car accident. He is restless; disoriented to person, place, and time; and agitated. He resists attempts at examination and calls out the name "Janice." Why should the nurse suspect delirium rather than dementia in this patient? a. The fact that he wouldn't have been allowed to drive if he had dementia b. His hyperactive behavior, which differentiates his condition from the hypoactive behavior of dementia c. The report of emergency personnel that he was noncommunicative when they arrived at the accident scene d. The report of his family that although he has heart disease and is "very hard of hearing," this behavior is unlike him

D Delirium is an acute problem that usually has a rapid onset in response to a precipitating event, especially when the patient has underlying health problems, such as heart disease and sensory limitations. In the absence of prior cognitive impairment, a sudden onset of confusion, disorientation, and agitation is usually delirium. Delirium may manifest with both hypoactive and hyperactive symptoms.

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

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.

What is the BRAND NAME for LAMOTRIGINE?

Lamictal (anticonvulsant)

What is the BRAND NAME for LITHIUM CARBONATE?

Lithonate, Lithotabs, Lithobid (antipsychotic; mood stabilizer)

What is the BRAND NAME for RISPERIDONE?

Risperdal (atypical antipsychotic)

What is the BRAND NAME for OLANZAPINE?

Zyprexa (atypical antipsychotic)