Week 6
The nurse is caring for a child newly diagnosed with autism spectrum disorder (ASD). Which of the following is the most appropriate overall outcome for this child? A) To function more effectively in social and emotional interactions B) To stay on task C) To acknowledge the effects of personal behavior on others D) To acknowledge personal strengths
A
An older adult client complains of periods of confusion and forgetfulness, but reports clear thought process at most times of the day. Which is the appropriate response from the nurse? A) "Are you having trouble hearing?" B) "You probably have nothing to worry about. It's most likely stress-related." C) "Everybody has a few problems with memory as they get older." D) "You should probably have an MRI of your brain."
A
An older adult client, hospitalized post-surgery, wakes up in the middle of the night very confused. The nurse reorients the client to the surroundings and gets the client to return to sleep. Which should the nurse consider as a source for the client's confusion? A) Ambien (zolpidem), a hypnotic/sedative, taken at bedtime for sleep B) The client's age C) The death of the client's husband last month D) History of cardiac disease
A
The nurse identifies a nursing diagnosis of Risk for Injury for a client who is disoriented. Which is an expected outcome for this client's care? A) The client does not sustain injuries during wanderings. B) The client remains continent of bowel and urine. C) The client receives culturally appropriate care. D) The client sleeps through the night and stays awake most of the day.
A
A 7-year-old child presents to the primary care office for a routine physical. Which question should the nurse include during the interview to identify the need for education related to preventing potential cognitive disorders? A) "Do you wear a helmet when you ride a bicycle or skateboard?" B) "How many times per day do you brush your teeth?" C) "How are your grades in school?" D) "How many hours per day do you watch television?"
A
A home health nurse visits a client with stage 2 Alzheimer disease who lives at home with a spouse. Which action by the nurse enhances the spouse's ability to meet the needs of the client? A) Encouraging the caregiver to obtain rest and eat a healthy diet B) Providing the client a list of daily activities to complete C) Making arrangements for the client to visit the local senior citizen center in the afternoon D) Finding placement in a long-term care facility
A
A nurse is caring for a client with Alzheimer disease (AD) who has receptive aphasia. Which area of the brain is likely damaged from AD? A) Temporal lobe B) Limbic system C) Frontal lobe D) Occipital lobe
A
A parent of a high school student with high-functioning ASD asks whether the child will ever be able to work. Which response by the nurse is best? A) "There are job training programs that assist adults with ASD." B) "Most adults with high-functioning ASD need to be supported by the state." C) "You should plan to provide care for your child for the rest of your life." D) "Individuals with high-functioning ASD usually grow out of the disorder."
A
A pediatric nurse is performing an assessment on a toddler who is suspected of having autism spectrum disorder (ASD). Which of the following questions to the parents would be least useful in gathering the information necessary to appropriately assess the toddler for this disorder? A) "Does your child have manic or depressed episodes?" B) "Tell me about your child's social interactions." C) "Does your child perform ritualistic behaviors when performing activities?" D) "Is your child able to name objects?"
A
The nurse is caring for a family with four children whose third child has been diagnosed with attention-deficit/hyperactivity disorder (ADHD). Which statement made by the mother suggests that the family may have difficulty coping with this diagnosis? A) "I don't know how to tell the rest of the family, and I'm not sure how we will manage the other children." B) "We need to alert the teachers at school as soon as possible so they can work with us to develop a plan that meets my son's needs." C) "What does this mean for my son's health in the future?" D) "Given this diagnosis, I'm not sure if we should let our son act in the school play."
A
The nurse is caring for a young school-age child who was recently diagnosed with attention-deficit/hyperactivity disorder (ADHD). Which statement by the child's mother requires follow up teaching? A) "I will let my child do homework while watching a favorite television show." B) "I will give my child ADHD medication with meals." C) "I will take my child to the doctor every 3 months for a weight and height check." D) "I will stick to the same routine each day after school."
A
The nurse is planning care for a client with stage 1 Alzheimer disease. Which are the priority nursing diagnoses for the client and family? A) Impaired Memory and Caregiver Role Strain B) Hopelessness and Functional Family Processes C) Knowledge Deficit and Ineffective Coping D) Pseudohostility and Ineffective Coping
A
The nurse is teaching the family of a client who has just been diagnosed with dementia. The family asks if there are treatments available that will cure the client. What would be the nurse's best response to the family? A) "There are no treatments that will cure dementia at this time." B) "Treatments to cure dementia include the use of vitamin E." C) "Treatments to cure dementia involve hormone replacement therapy." D) "There are no treatments that can slow the progression of the disease."
A
While assessing the cognitive status of a school-age child, the nurse notes that the child was unable to perform basic mathematical problems and unable to name several former presidents of the United States. Prior to considering the possibility that this client has cognitive issues, which factor should be reviewed? A) The child's age and developmental status B) The child's living arrangements with separated parents C) The child's currency of vaccinations D) The child's hobbies performed in leisure time
A
A client is diagnosed as having stage 1 Alzheimer disease. Which are appropriate goals for the client and family at this time? Select all that apply. A) Resolving grief over the diagnosis B) Deciding on the desired treatment and selecting a healthcare proxy; sharing the treatment decision with the healthcare proxy C) Beginning cognitive-enhancing medication, such as Aricept D) Setting up a protective physical environment—such as removing throw rugs E) Making provisions for assistance with activities of daily living (ADLs)
A,B,C,D
An adult child brings a parent in to be evaluated and is told the client has Alzheimer disease. The adult child asks the nurse if he is also at risk for the disease. Which risk factors should the nurse include when responding? Select all that apply. A) Genetic predisposition B) Age C) History of hypertension D) Hearing deficits E) Gender
A,B,C,E
A nurse is preparing an educational program for clients in a long-term care facility regarding protective factors for Alzheimer disease (AD). Which information should the nurse include? Select all that apply. A) Becoming involved in activities such as reading that keep the mind active B) Incorporate a high-calorie, high-carbohydrate diet to decrease formation of amyloid plaques C) Remain socially active D) Including modest exercise into daily regimen E) Begin drinking a glass of wine each night before bed
A,C,D
The nurse is providing education to the parents of a child diagnosed with ASD. Which of the following healthcare professionals should the nurse tell the parents will take part in their child's care? Select all that apply. A) Social services B) Laboratory C) Speech therapy D) Play therapy E) Public health agency
A,C,D
Which is true regarding the aging process and cognition? A) Generally, older adults' short-term memory changes significantly. B) Generally, many older adults have increased difficulty finding and rapidly listing words. C) The ability to use and understand word combinations declines steadily with age. D) The ability to acquire practical information declines steadily with age.
B
A client presents with signs and symptoms of early Alzheimer disease. What would be used to confirm this client's diagnosis? A) Abnormal CT scan findings of plaques and tangles in the brain B) Client history and physical examination C) Positive blood tests for beta-amyloid and tau proteins D) Blood test for amyloid plaques and neurofibrillary tangles
B
A client with dementia is prescribed donepezil (Aricept). Which should the nurse consider when teaching this client about the medication? A) Donepezil shortens the early stages of Alzheimer disease. B) Donepezil is an acetylcholinesterase inhibitor that has a modest effect in slowing the progression of Alzheimer disease. C) Donepezil is an anticholinergic and has been known to eradicate some of the symptoms associated with Alzheimer disease. D) Donepezil should be taken on an empty stomach.
B
A community health nurse is teaching a group of women about the dangers of smoking. Which of the following child health problems should the nurse mention as associated with smoking during pregnancy? A) Benzodiazepine withdrawal B) Attention-deficit/hyperactivity disorder (ADHD) C) Vision impairment D) Personality disorders
B
A nurse is assessing a child who shows marked abnormalities in speech patterns. These includes using you in place of I, parroting words and phrases, and repeating questions rather than answering them. The nurse should recognize that these are characteristic of which condition? A) Cerebral palsy B) Autism spectrum disorder C) Attention-deficit/hyperactivity disorder (ADHD) D) Failure to thrive
B
A nurse is assessing a client diagnosed with Alzheimer disease (AD) in which the family reports that the client recently lost the ability to live independently and is unable to perform certain activities of daily living (ADLs) such as selecting appropriate clothing or preparing meals. The family's report indicates that the client has progressed to which stage of AD? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4
B
A nurse is caring for a child who has been diagnosed with attention-deficit/hyperactivity disorder (ADHD). The client's healthcare provider has prescribed amphetamine-dextroamphetamine (Adderall) to treat the child's disorder. Which of the following statements regarding the use of this medication is appropriate for the nurse to include in the medication teaching? A) "Your child's liver function should be monitored with this medication." B) "Your child's growth will need to be monitored on this medication." C) "This medication may increase the risk of psychosis." D) "This medication has less abuse tendency because it is not a stimulant."
B
A nurse is providing education to the caregiver of a child with autism spectrum disorder (ASD). Which commonly associated behavioral problem should be identified in this teaching? A) Depression in relation to feelings of inadequacy B) Episodes of self-injury C) Strong tendency toward hypoactivity D) Hostility when faced with structured environments or repetitive activities
B
A school-age client is hospitalized with encephalitis and is experiencing delirium. Which intervention promotes a therapeutic environment for this child and family? A) Making sure the parents perform all treatments for their child B) Encouraging the family to remain at the bedside with the client C) Making sure the child comes back for the follow-up appointment D) Providing written instructions before discharge
B
An older adult client comes into the clinic for a pneumonia vaccine. During the client interview, the client reports occasionally having difficulty remembering some words, but denies any other concerns. The client is alert and oriented to time, person, and place, and most responses are appropriate. How should the nurse describe this client's cognitive changes? A) Memory impairment that may be related to cerebral ischemia B) Normal signs of aging C) Indicators of depression in the elderly D) Early symptoms of dementia
B
Damage to which region of the brain may result in loss of recent memory? A) Neuron B) Hippocampus C) Cerebrum D) Neurotransmitter
B
The family of an older adult client is informed that the client has delirium. Which statement indicates that the family understands the diagnosis? A) "It's sad that dad is getting dementia." B) "The changes in his behavior came on so quickly, which may be the result of an underlying medical condition." C) "Our father is going to need long-term psychiatric care." D) "Confusion is normal in older adults, and it goes away on its own."
B
The nurse is assessing an older adult client and observes that the client is having several cognitive problems, including memory and attention deficits and fluctuating levels of orientation. The nurse confirms with the family that the client's symptoms developed over a several-year period. The client's symptoms are commonly observed with which condition? A) Depression B) Dementia C) Intellectual disability D) Delirium
B
The nurse is caring for a client who becomes confused and agitated every evening. Medical reasons for the change in mental status have been ruled out. The nurse correctly communicates to the other healthcare team members that the client is experiencing which phenomenon? A) Delirium B) Sundowning C) Aphasia D) Chronic psychosis
B
The nurse walks into the client room, and the client is confused and disoriented. Ten minutes prior, the client was oriented to person, place, and time and was not confused. Which nursing action is priority? A) Position client in supine position B) Assess vital signs and pulse oxygenation C) Ambulate client to encourage lung expansion D) Obtain urine for urinalysis
B
The school nurse is talking to a child with attention-deficit/hyperactivity disorder (ADHD) who wants to play soccer. Which action is most appropriate for the school nurse to take? A) Recommend that the child become active in an individual sport, rather than a team sport. B) Encourage the child to play soccer. C) Discourage the child from playing a sport. D) Ask the child's mother to get permission from the child's physician to play soccer.
B
The staff on a care area that has a high percentage of clients with confusion attends an educational program on delirium management. Which statement, made by a staff nurse, indicates that teaching has been effective? A) "It is important to provide education for family members as needed." B) "Sensory deprivation and overstimulation can worsen the symptoms the client exhibits." C) "Decreasing all stimulation in the client's room is essential." D) "The family should involve the client in all conversations and interactions involving care."
B
Which clinical manifestation of ADHD is more commonly observed in school-aged girls than in school-aged boys? A) Aggression B) Anxiety C) Sleep disturbances D) Impulsiveness
B
The nurse is caring for a client with perceptual disturbances who is becoming agitated. Which action should the nurse take first? A) Distract client by taking into the dayroom to watch television with other clients. B) Administer medications to sedate client before violent behaviors occur. C) Request client to go back to room and dim lights. D) Do nothing, as this is a normal manifestation of disturbed cognition.
C
A nurse manager is educating a group of staff nurses on recognizing the differences between confusion and delirium. Which statements should be included in the teaching? Select all that apply. A) "Delirium is seen only in older adults." B) "Delirium is a reversible condition while dementia is not." C) "Older adults are at higher risk for developing delirium." D) "Younger adult females are at higher risk for developing delirium." E) "Adolescents are more prone to developing delirium than young children."
B,C
The nurse is caring for a school-age client who was admitted with pneumonia and high fever. The parents are very upset because the child is now unable to recognize them. Which statements should the nurse include while educating the parents on their child's symptoms? Select all that apply. A) Reorient the client to time and place as much as possible. B) Encourage the family remain at the bedside as much as possible. C) Explain that high fevers can cause delirium. D) Reassure that the confusion will not last very long. E) Teach the family how to care for the child upon discharge.
B,C
The family of an older adult client is concerned about the changes in the client's behavior. The client used to be a wonderful cook but now cannot even remember how to use a blender. For which causes of impaired cognitive function should the nurse assess the client? Select all that apply. A) Obesity B) Nutritional deficiencies C) Medication reactions D) Stroke E) Snoring
B,C,D
Which should the nurse identify as risk factors for a pregnant client having a baby with autism? Select all that apply. A) Employed as a computer programmer B) Smokes one pack per day of cigarettes C) Drinks two glasses of wine on the weekends D) Age 40 E) Rides a stationary bicycle four times a week for 30 minutes
B,C,D
The nurse plans a class about Alzheimer disease for a caregiver support group. Which should the nurse include when teaching this class of caregivers? Select all that apply. A) Glutamatergic inhibitors are the most common class of drugs for treating Alzheimer disease. B) Alzheimer disease accounts for about 80% of all dementias. C) Chronic inflammation of the brain may be a cause of the disease. D) Depression and aggressive behavior are common with the disease. E) Memory difficulties are an early symptom of the disease.
B,C,D,E
The nurse is planning care to address safety needs for an older adult client who has recently been diagnosed with early Alzheimer disease. Which interventions are appropriate to address safety needs? Select all that apply. A) Use of a restraint belt at night to prevent wandering behaviors B) Check shoes for fit and support. C) Contact the department of motor vehicles to have the client's license suspended. D) Keep all familiar objects in the home. E) Remove throw rugs and electrical cords.
B,E
A client with Alzheimer disease is scheduled to attend occupational therapy three times a week. Which is the purpose of the client attending this type of therapy? A) Improve language deficits B) Improve muscle tone C) Ability to perform activities of daily living D) Improve access to community organizations
C
A community health nurse is educating pregnant clients about the risk factors associated with the development of attention-deficit/hyperactivity disorder (ADHD). Which statement will the nurse include in the educational session? A) "ADHD has not been linked to prenatal exposure or disease." B) "ADHD has been linked to a specific gene, and genetic testing may help to diagnose this." C) "ADHD has been linked to prenatal exposure to cigarette smoke." D) "ADHD has been linked to childhood exposure to folate."
C
An individual with ASD who demonstrates marked distress on switching activities (such as responding with loud verbalizations and behaviors that could result in self-harm) is demonstrating which level of clinical manifestations of the disorder? A) Level I clinical manifestation B) Level II clinical manifestation C) Level III clinical manifestation D) Level IV clinical manifestation
C
An older adult client with no history of cognitive impairment is suddenly showing signs of increased confusion and possible delirium. Which health problem should the nurse suspect is causing this client's confusion? A) Cataracts B) Hypertension C) Urinary tract infection D) Lower back strain
C
Assuming approximately the same birth weight, level of prenatal care, and level of genetic predisposition, which of the following infants is least likely to develop ADHD during childhood? A) An infant born at 35 weeks' gestation B) An infant born at 36 weeks' gestation C) An infant born at 38 weeks' gestation D) An infant born at 34 weeks' gestation
C
The nurse is caring for a child diagnosed with autism spectrum disorder (ASD) who is being admitted to the hospital with dehydration. Which action by the nurse is appropriate when the child arrives to the care area? A) Take the child on a tour of the pediatric unit. B) Take the child to the playroom for arts and crafts. C) Quietly orient the child to a single-bed hospital room. D) Orient the child to a four-bed unit.
C
The nurse is caring for an adult client with ASD. He indicates that he struggles with finding and maintaining employment. Which action by the nurse best addresses the client's needs? A) Give the client information about state subsidies that will help him get by without a job. B) Suggest the client work for a business owned by a family member or family friend. C) Ask the client what his strengths are and identify types of jobs based on those strengths. D) Encourage the client to seek opportunities that do not require communication with others.
C
The nurse is educating the family and client, who was recently diagnosed with Alzheimer disease (AD), regarding long-term care placement. Which is the rationale for providing this information to the family at this time? A) It often takes 6 to 12 months for an individual with AD to establish a successful transfer to a facility, and this will allow adequate time. B) It's better to address the issue of placement now instead of later. C) Early introduction to long-term options will allow the client and family time to make a more informed decision. D) Long-term care placement is inevitable with this diagnosis.
C
The nurse is explaining the difference between delirium and dementia to a family member of a client with confusion. Which statement is appropriate for the nurse to include? A) "The cause of delirium is always unknown." B) "Dementia develops suddenly." C) "Delirium is a serious but common occurrence in older adult clients who are hospitalized." D) "Delirium is often confused with depression in older adult clients."
C
The nurse is planning care for a client who is experiencing stage 1 Alzheimer disease. Which intervention will best promote cognitive function? A) Ensure there is background music or sound from the television. B) Dim the lights during waking hours. C) Maintain a daily routine. D) Keep social interaction to a minimum.
C
The nurse is reviewing pharmacologic treatments with a caregiver of an individual with Alzheimer disease. Which statement indicates that teaching has been effective? A) "There are effective drugs, but they cannot be used over a long period." B) "There aren't any drugs that are effective in treating this disease." C) "The earlier the drugs are started, the greater the likelihood they will have benefits." D) "There are drugs that can control symptoms for many years."
C
A hospitalized older adult client suddenly does not recognize an adult daughter and states, "Why hasn't my wife come to see me?" The client's spouse has been deceased for 5 years. Prior to the hospitalization, the client was oriented to person, place, time, and reality. Which nursing diagnoses would be appropriate for this client? Select all that apply. A) Risk for Autonomic Dysreflexia B) Anxiety C) Acute Confusion D) Risk for Injury E) Ineffective Coping
C,D
A client diagnosed with Alzheimer disease becomes agitated during an activity involving simultaneous music playing and a craft project. The client starts shouting, "No! No! No!" and runs from the room. Which action by the nurse is the most appropriate? A) Administer a prn anti-anxiety medication. B) Restrict participation in any group activities. C) Call security and prepare physical restraints. D) Reassure the client and then redirect to a quiet area.
D
A nurse is caring for a school-age client who is scheduled to have a tonsillectomy the next day. The nurse has planned a preoperative teaching session for the child, who has a history of attention-deficit/hyperactivity disorder (ADHD). Which teaching technique is most appropriate for this client? A) Play a video describing the procedure to the child. B) Ask other children who have had this procedure to talk to the child. C) Allow the child to lead the teaching session to gain a sense of control. D) Give instructions verbally and use a picture pamphlet, repeating points more than once.
D
A nurse is completing a psychosocial assessment of an adult client. Which finding is most consistent with an adult who has ADHD? A) "The client stated that he has many friends and an active social life, and he thrives in fast-paced environments." B) "The client stated that at times he feels tired and listless, struggling to get out of bed and complete basic self-care tasks." C) "The client stated that he feels confident when completing job tasks and is punctual and effective at work, even though he has difficulty getting along with coworkers." D) "The client stated that he struggles with alcohol use and often engages in unprotected sex and recreational drug use."
D
The nurse is educating a client who is diagnosed with stage 1 Alzheimer disease (AD) and the client's spouse. Which suggestion best promotes maintaining functional ability at this stage? A) Obtain round-the-clock care at home B) Prepare liquid nutrition C) Assist client with ADLs D) Begin making "to-do" lists and use of a calendar
D
The nurse is interviewing the mother of a child who is being evaluated for attention-deficit/hyperactivity disorder (ADHD). When assessing the child's health history, which of the following should the nurse identify as a risk factor for ADHD? A) The measles, mumps, and rubella (MMR) vaccine B) The immune response of the child C) Young parental age at conception D) Smoking during pregnancy
D
The nurse is teaching the family of a child who is prescribed amphetamine mixed salts sustained release (Adderall XR) for attention-deficit/hyperactivity disorder (ADHD). Which of the following should the nurse teach the family is the best time to administer the medication? A) Just before lunch B) At bedtime C) With the evening meal D) Early in the morning
D
The parent of a child with autism spectrum disorder (ASD) asks why family therapy has been prescribed. Which response by the nurse is most appropriate? A) "Family therapy will help you learn how to assess your child's potential." B) "Family therapy will provide your child with an opportunity to learn problem-solving skills." C) "Family therapy will help you interact with your child." D) "Family therapy will help you learn how to cope with your child's diagnosis."
D
The parents of a child with autism spectrum disorder (ASD) observe that the child has difficulty making friends and are concerned about social expectations for their child. Which of the following is the priority diagnosis for this child based on the parents' concern? A) Ineffective Coping B) Deficient Diversional Activity C) Social Isolation D) Impaired Social Interaction
D
The spouse of a client with Alzheimer disease does not understand why the client developed the disorder because no one else in the family has the health problem. Which response by the nurse is appropriate? A) "Alzheimer disease develops because of smoking and alcohol intake." B) "Someone in your family must not have been correctly diagnosed with the disorder." C) "Alzheimer disease does not have the same course in every individual." D) "There are genetic and environmental factors in the development of Alzheimer disease."
D
Which is true regarding the Confusion Assessment Method (CAM)? A) It consists of five parts and is a lengthy test. B) It measures the severity of the client's delirium. C) It is also effective in screening for depression. D) It is effective in screening for cognitive impairment and reversible confusion.
D
Which is true regarding the pathophysiology and etiology of Alzheimer disease? Select all that apply. A) Damage to the limbic system results in speech decline and slowed movements. B) Familial Alzheimer disease (eFAD) is also called delayed-onset Alzheimer disease. C) Sporadic Alzheimer disease usually manifests before age 65. D) Sporadic Alzheimer disease is more common than familial Alzheimer disease. E) In Alzheimer disease, neuronal cells die in a characteristic order.
D,E