39: Cognitive Processes
Which statement is true regarding dementia?
It is a progressive impairment of intellectual function and memory. People with dementia experience a gradual decline in all cognitive processes. It is not associated with disturbance in level of consciousness, but it does interfere with social or occupational functioning.
A nurse is working at a well-child clinic. Which client would the nurse most likely identify as being capable of abstract thinking?
15-year-old During adolescence, teenagers become able to think abstractly and to perform complex mental processes. Preschoolers and school-aged children are not capable of thinking abstractly.
A nurse is assessing a client's mental status using the Mini-Mental State Examination. Which score would lead the nurse to suspect that the client is experiencing significant cognitive impairment?
18 A score of 20 or less on the Mini-Mental State Examination indicates significant cognitive impairment
A nurse is developing an education plan for the family of a client with dementia and plans to describe normal cognitive processes, including how these processes are affected by the client's condition. Which term would the nurse use to describe the ability to concentrate and take in specific stimuli?
Attention Attention is the ability to concentrate on, and take in, specific sensory stimuli. Memory is the ability to recall a thought at least once and usually again. Learning is the capability of the nervous system to store memories. Communication is the exchange of information between at least 2 people and involves the use of language to store, process, and transmit thought content.
A group of nursing students is developing plans of care for assigned clients with cognitive problems based on their understanding of cognition. The students demonstrate a sound knowledge base when they integrate which statement into the plans of care?
Intelligence consists of memory, comprehension, and concentration. Intelligence consists of memory, comprehension, and concentration. Comprehension, not memory, means the ability to grasp the meaning of stimuli. Intelligence is not abstract; it is a measurable product of intellectual functioning. Concentration, not comprehension, means the ability to filter extraneous stimuli to focus on a task.
After teaching a class on normal cognitive function, the instructor determines that the teaching was successful when the class identifies which structure as being important to auditory sensation and meaningful sound.
Organ of Corti The organ of Corti and cochlea are important for auditory sensations and meaningful sound. The reticular activating system is essential for maintaining wakefulness and in controlling vital cardiovascular reflexes. The spinothalamic tract is responsible for carrying sensory nerve impulses. The retina is important for vision and interpretation of images.
A nurse is providing care to a client who is experiencing sleep deprivation. The nurse understands that a disruption in which stage of the sleep cycle would most interfere with the client's cognitive function?
REM Rapid eye movement (REM) sleep seems to be particularly important to efficient cognitive functioning. Inadequate REM sleep may impair both learning and memory and decrease the subjective feeling of being rested. Disruption of the other stages of sleep are not associated with changes in cognition.
the pediatric nurse walks into the room of a 4-year-old child who has been hospitalized for cancer treatment and finds the child crying and upset. Upon questioning, the child tells the nurse, "I would not be sick if I had only obeyed mommy and daddy." Which is the best response from the nurse?
Reassure the child he or she did not cause the illness A 4-year-old child is in the process of making sense of the world or learning reasoning. Children this age often use transductive reasoning or believing when two events occur simultaneously, one caused the other. The nurse should reassure and comfort the child and allow the child to ask questions and provide truthful answers. It would be inappropriate to scold the child or instruct the child to behave the next time as that would reinforce this false concept. In the discussion with the parents, the nurse should let the parents know this is happening and assess how they are handling the situation.
As part of a presentation on cognition, a nurse is planning to discuss the concept of consciousness and how the nervous system is involved. Which structure would the nurse identify as being responsible for mediating the level of arousal?
Reticular activating system Consciousness, a state of awareness and full responsiveness to stimuli, relies on an intact RAS and cerebral cortex. The RAS mediates level of arousal, and the cerebral cortex mediates perception and interpretation of stimuli. Perception depends on functioning sensory receptors, neurotransmission, and central processing.
A nurse is assessing a client who is experiencing significant impairment of his long-term memory. The nurse understands that this is most likely due to:
central nervous system disorder. Situational and emotional stress usually has few effects on long-term memory. Significant impairment of long-term memory usually indicates a CNS disorder or a severe confusional state. Electrolyte imbalances can affect cognitive status overall.
The wife of a 75-year-old client with delirium asks the nurse about her husband's condition. Which statement would be most appropriate? Select all that apply.
"Medications are a common cause for this condition." "The changes that you are seeing are temporary." "Your husband's condition is reversible." Delirium is quite common among hospitalized clients; as many as 80% of clients in intensive care units and up to 30% of clients in acute medical surgical units will experience delirium. An important aspect of delirium is identifying the cause, which often may be related to medications that the client is receiving. Delirium, unlike dementia which is permanent and progressive, is reversible and the symptoms resolve once the cause is determined and treated.
The nurse is providing education to a group of older adults. Which suggestion(s) will the nurse make to the group to help cope with changes in perceptual ability as a person ages? Select all that apply.
- Look at expiration dates of food rather rely on sense of smell. - Lower water heater temperature to prevent burns due to diminished sense of touch. - Utilize herbs and spices to enhance the taste of foods. - Have hearing tested to determine hearing loss. - Remove safety hazards that could be missed with poor vision. As people age, perceptual ability, which contributes to cognitive functioning, declines as sense organ functions diminish. These normal changes affect the ability to organize incoming stimuli. By educating on all of the listed techniques the nurse will provide the clients with information to work around deficits that may occur with aging.
The nurse is caring for several clients in a long-term care facility. Which client would receive the most benefit from the inclusion of reminiscence therapy when creating the plan of care?
An older adult client with short-term memory loss from Alzheimer disease. Reminiscence therapy, a type of socialization therapy, involves clients in using recall of the past to clarify meaning in the present or reconcile conflict. The client that would most benefit from this form of therapy would be a client that has retained long-term memory and is able to recall events from the past. The client that is in the long-term care facility for short-term rehabilitation is not going to receive benefit from this form of therapy. A client that is nonverbal will not be able to participate in the therapy sessions and may become frustrated. Reminiscent therapy may not bring back positive memories for a client that has no family and was alone prior to the admission.
A nurse is concentrating on a specific task without being distracted by other things in the environment. The nurse is demonstrating:
Attending Attending is the process of concentrating on a specific stimulus without being distracted by other, irrelevant stimuli. Perceiving is the process of receiving and interpreting sensory stimuli that function as a basis for understanding, knowing or learning. Thinking is the process of sorting, organizing, and categorizing information to form mental concepts or perceptions. Learning is a multidimensional process of acquiring knowledge that depends on abstract functions (such as symbols, language, classifications, and concepts) as well as concrete operations.
A nurse is providing care to a client with a diminished sense of smell. Which intervention will the nurse implement for this client?
Describing foods during meal delivery Taste and smell seem to be closely related because diminished function in one usually affects the function of the other. By describing what food is on the plate, the client will be able to identify foods without the sense of smell. Additional seasoning may be necessary for a client with a diminished sense of taste. A client with a visual impairment will require assistance with the location of foods presented. A client with a diminished sense of touch will need to have hot and cold food locations described while serving a meal.
A family is moving an older adult parent to a memory care home due to dementia progressing to a point where the family can no longer care for the parent. The staff should inform the family that which condition will probably occur as the parent makes the transition from one home to the next?
Disorientation The stress of an unfamiliar environment can affect this underlying cognitive process of orientation. The staff should inform the family it may take several weeks for the client to become familiar with the changes. Combativeness, depression and sleep deprivation may be the result of the disorientation but not all individuals display these actions.
Which step would the nurse take first to identify delirium when caring for clients who are at risk?
Know the client's baseline cognitive status. Nurses must identify delirium early and ensure interventions are in place that will hasten delirium and mitigate potential complications associated with undiagnosed delirium. The first step in delirium identification is to know the client's baseline cognitive status. Identifying the cause, including a review of the client's medications, would be undertaken once the nurse has identified that changes indicating delirium have occurred. Reorienting the client is an intervention completed once the delirium has been identified.
Which structures are involved in speech production? Select all that apply.
Larynx Nasal cavity Tongue The larynx, nasal cavity, and tongue are all involved in speech production. Semicircular canals are part of the inner ear and the organ of Corti. In response to vibration, hair cells of the organ of Corti generate nerve impulses that the cochlear nerve, in company with the vestibular nerve, carries to the central auditory pathway.
A nurse is performing a comprehensive assessment of a client's cognitive function. Which evaluation(s) would the nurse most likely include? Select all that apply.
Level of consciousness Mental status exam Behavior Verbal ability Levels of consciousness and orientation are not by themselves adequate assessments of cognitive function. Comprehensive assessment includes the use of a mental status questionnaire (such as Folstein's Mini-Mental State Examination) and a behavioral rating scale (such as the classic Clinical Assessment of Confusion-A or the NEECHAM Confusion Scale). The need for a speech evaluation would be indicated based on the findings of the comprehensive exam.
An adult client diagnosed with COVID-19 who was previously alert and oriented is now becoming confused. Which assessment data will the nurse correlate with increasing confusion?
Oxygen saturation (SPO2) level of 85% Signs of confusion can be attributed to a lowered blood oxygen saturation (SPO2) level. A normal reading is typically between 95% and 100%. Loud, high-pitched bronchial breath sounds over the trachea are normal findings. A respiratory rate of 20 breaths/min is normal. Normal peak flow will vary according to height, age and gender. Adults should achieve readings of 400 to 700 L/min, with men generally higher.
A nursing instructor is describing normal cognitive patterns. Which term would the instructor use to describe the receiving and interpreting of sensory stimuli that function as a basis for understanding, knowing, or learning?
Perceiving Receiving and interpreting sensory stimuli is called perceiving. Attending means concentrating on a specific stimulus without being distracted by other, irrelevant stimuli. Thinking means sorting, organizing, and categorizing information to form mental concepts or perceptions. Learning means acquiring knowledge.
While caring for a client, the client says, "See this rose my son sent me. It is such a beautiful flower." The nurse interprets this statement as indicating which characteristic of normal cognition?
Recognition Recognition is the ability to relate accurately something in the current environment with what is stored in memory (e.g., seeing a rose and "recognizing" it as a type of flower). Recall involves the ability to retrieve information directly or by relating it to other information (e.g., seeing a person and "recalling" his name accurately). Language is the ability to convey needs, ideas, and feelings through the systematic use of symbols. Judgment, or insight, is the process of reasoning. It is the ability to process incoming stimuli and to determine the complex meanings associated with many aspects of a situation. Orientation is the basic process by which people know their location in the dimensions of time and place. Orientation also includes the ability to know who one is as a person and in relation to others.
A nurse is developing an in-service education program for a group of nursing assistants. The nurse is planning a discussion on ways to help promote reality orientation for clients experiencing cognitive deficits. Which of the following would the nurse be least likely to include in the discussion?
Rotating caregivers to prevent staff stress and burnout Maintaining a structured environment assists patients in adapting to cognitive alteration and in reestablishing communication. Structured routines, such as assigning staff to consistently care the same clients, rather than rotating staff caregivers minimize the number of factors on which patients must focus. Sequenced events, consistent daily schedules and care providers, calendars, and frequent reminders contribute to structure.
A nurse is engaging in therapeutic communication with a client who has chronic confusion. Which action would be most appropriate for the nurse to do?
Sit at eye level with the client. Therapeutic communication with clients who have chronic confusion may be enhanced by assuming a nonthreatening posture (e.g., sitting at eye level with the client). Explain what you are going to do in a calm, friendly tone of voice. Avoid using commands or asking "Why" questions. Do not try logically to persuade a resistive client to comply with your requests. Do not try to argue or change the client's beliefs; instead, deal with the client's reactions to the beliefs. Accept that the client may have a distortion of reality and focus on the feelings that are related.
Which statement is true regarding how fluid and electrolyte balance can affect cognitive functioning?
The brain's cellular processes depend on the active and passive movement of water and electrolyte movement across cell membranes. Movement of water and electrolytes via active and passive movement maintains a balance of each and protects cells, including brain cells, against cellular damage.
An 87-year-old woman has just moved into a nursing home after being in an independent retirement facility. Since the move, she has been experiencing a progressive decline in her cognitive functioning. Her room is located across from a nursing station so that she can be observed at all times. Her daughter continues to visit every day for breakfast and has noticed that her mother is showing signs of depression. Since moving, she has become increasingly confused. Which factor is not contributing to this increase in confusion?
The client's daughter continues to visit at the same time each day. The acceleration of the client's decline in cognitive functioning is multifactorial. Being in an unfamiliar environment is affecting her cognitive process of orientation. Being close to a nurse's station, which is typically noisy, adds to the amount of stimuli she is receiving; this can serve to decrease her ability to find meaning in what she is sensing. Also, depression interferes with cognitive function and can contribute to altered thought processes. The fact that the client's daughter visits her every day at the same time can actually provide an orienting cue which may help decrease the client's confusion.
A nurse sees a client walking slowly down the hall. The client is swaying to one side and is observed grabbing onto a chair that is nearby. Which example demonstrates the cognitive process of judgment?
The nurse determines the client is about to fall and takes action to prevent it. The nurse's action to prevent a fall indicates judgment, which is the process of reasoning and the ability to process incoming stimuli in order to determine the complex meaning associated with the many aspects of the situation. Recall involves the ability to retrieve information directly or by relating it to other information. The nurse stopping to ask the client about the action is an example of a nursing observation but not an example of judgment. The nurse preventing the problem from happening again is an example of learning.
A nurse is assessing a client who has developed altered cognition secondary to an infection. The nurse understands that which type of infection is a common cause? Select all that apply.
Urinary tract Respiratory system Wound Nervous system Infectious processes of the CNS, including encephalitis and brain abscesses, and the subsequent inflammatory response of nerve cells, are obvious causes of altered cognition. HIV can invade the CNS, causing acute infection or progressing to AIDS. Infections elsewhere in the body can also cause changes in mental status. Any person with a severe infection in the circulation (e.g., bacteremia, septicemia) may experience CNS effects, including lethargy and confusion. Common sources for bacteremia or septicemia include the urinary tract, respiratory system, and any open wounds. Infection of the gastrointestinal tract is not a common cause.
A nurse is providing care to a client who has a history of stroke. The nurse understands that this client is at risk for which type of dementia?
Vascular dementia Vascular dementia (VaD) is a term that refers to cognitive impairment caused by arterial brain lesions. Clients with previous stroke are at high risk for developing vascular dementia with or without onset of new ischemic injuries. Alzheimer's disease involve progressive cerebral atrophy or shrinking of the cortex. Frontotemporal dementia refers to the clinical manifestations of nerve cell loss and impairment of the frontal and anterior temporal lobes. Is it not associated with stroke. Lewy body dementia involves clumps of protein aggregating which eventually cause neurodegeneration over time.
The nurse assesses a client and suspects that the client may be experiencing hypoactive delirium. Which finding would support this suspicion? Select all that apply.
Withdrawn behavior Lethargy Sedated appearance Hypoactive delirium is often termed "quiet delirium" because clients are withdrawn, lethargic, and appear sedated. Clients are agitated in hyperactive delirium and often disruptive within the unit.
A nurse is preparing a presentation for a group of new nurses about the perception of information. As part of the presentation, the nurse plans to talk about how touch and pressure are transmitted. Place the steps below in the correct order that depicts the transmission. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left.
activation of somatic skin sensors impulse traveling through the spinal cord impulse traveling through the thalamus impulse traveling through to the parietal lobe Touch, pressure, heat, cold, or chemicals in the tissue activate somatic sensors in the skin. Resulting nerve impulses enter the spinal cord through the posterior roots. From the spinal cord, sensory information is transmitted through the thalamus to the somatosensory cortex in the brain's parietal lobes.
A nurse is developing a plan of care for a client with dysarthria. Which of the following would be a priority intervention?
having the client fully upright when eating Dysarthria refers to speech disorders that result from a disturbance of motor control, weakness, paralysis, or incoordination of the oral musculature. Clients with dysarthria need to be evaluated and treated by a speech therapist to ensure safe swallowing. Therefore, the client should be placed in a full upright position for eating, and offered foods with texture and consistency and thickened liquids. If the client cannot consume adequate calories safely, then tube feedings may be necessary.
A nurse is providing care to a client who is experiencing an altered level of arousal. While observing the client, the nurse notes that the client becomes startled at an unexpected noise. The nurse documents this level of arousal as:
hypervigilant. Arousal is a person's level of reactivity to incoming stimuli. Levels of arousal may be categorized as hypervigilant, alert, lethargic, obtunded, and comatose. Hypervigilant means the person is acutely aware of environmental stimuli and may startle at unexpected noise; hypervigilance is often accompanied by a decreased ability to concentrate. Alert means the person is awake and fully aware of incoming stimuli. Lethargic describes the client who is not fully awake and tends to drift off to sleep when not actively stimulated. Obtunded describes the client who is difficult to arouse and when aroused is confused. Coma describes the client who is completely unresponsive to incoming stimuli.
A group of nursing students is reviewing information about cognition. One of the students gives the following example: A driver sees a truck blocking the road ahead and decides to stop his vehicle. The student then asks the other students which characteristic of normal cognition the driver is demonstrating. The students demonstrate understanding of the information when they identify the characteristic as:
judgement The driver shows judgment or insight. He processes the incoming stimuli of seeing a truck blocking the road and determines that this could mean a potential crash; therefore, he stops his own vehicle. Orientation means knowing oneself and one's location in the dimension of time and place. Recall involves the ability to retrieve information directly or by relating it to other information. Recognition is the ability to relate accurately something in the current environment with what is stored in memory.
A nurse is providing care to a client with an impairment in cognitive function. Which recommendation would be most appropriate to include in the client's plan of care? Select all that apply.
maintaining a structured environment providing frequent reminders minimizing distractions For the client with impaired cognition, the nurse should maintain a structured environment, minimize distractions, provide environmental cues and frequent reminders, and gently correct the client when he is wrong or provides false answers.
A client with mild memory impairment is being discharged home to be cared for by his family. When educating the family about caring for the client, which aspect would the nurse emphasize?
need for a predictable environment For people with minor memory impairment, various ways to support and compensate include making lists of medications to take, of things to do, or of appliances to turn off. Maintaining organization in the home and with routines creates a predictable environment with few distractions so that a person's memory functions more effectively. Although stimulation is important, the client needs a routine; thus, new experiences should be limited so as not to upset the client's routine. There is no need for speech therapy for mild memory impairment.
A client with an altered level of arousal is difficult to arouse and becomes confused when he is awakened. The nurse identifies this level of arousal as:
obtunded Arousal is a person's level of reactivity to incoming stimuli. Levels of arousal may be categorized as hypervigilant, alert, lethargic, obtunded, and comatose. Obtunded describes the client who is difficult to arouse and when aroused is confused. Hypervigilant means the person is acutely aware of environmental stimuli and may startle at unexpected noise; hypervigilance is often accompanied by a decreased ability to concentrate. Alert means the person is awake and fully aware of incoming stimuli. Lethargic describes the client who is not fully awake and tends to drift off to sleep when not actively stimulated. Coma describes the client who is completely unresponsive to incoming stimuli.
A nurse is developing a plan of care for a client diagnosed with schizophrenia. The nurse develops interventions based on the understanding that:
the client shows distortion of reality and difficulty processing information. A client with schizophrenia shows distortion of reality and difficulty processing information. The brain shows an excess of, not decrease in, the neurotransmitter dopamine. There is a decrease, not an increase, in the number of dopamine receptors in the brain. There is an increase in confusion and agitation at the end of the day in clients with sundown syndrome, not schizophrenia.
A client is diagnosed with late stage Alzheimer's disease. The client is being cared for at home with the help of his son, the son's family, and home care services. The son tells the home care nurse, "We're just so tired. Caring for my father is really tough." Which suggestion would be most appropriate for the son and his family at this time.
"Let's talk about possibly getting you and your family some respite care." The son is verbalizing fatigue from caring for his father. The most appropriate suggestion would be to offer the son some respite services to give him and his family some time away from caregiving, while providing his father with health and rehabilitative services. This response addresses the son's needs. If the son had stated that he can no longer care for his father, then a referral to a long-term care setting might be appropriate. However, it is the son's decision, not the nurse's decision. Additional home health care services may help over the long term, but the son and his family need a break now. Music therapy would not alleviate the fatigue that the client's son and family are experiencing.
A client comes to the clinic for an examination. During the visit, the nurse evaluates the client's cognitive function using the Mini-Mental State Examination. On previous visits, the client's score was 28. The nurse determines that the client is experiencing a significant decline in his cognitive function based on which score?
20 Although scores of 22, 24, and 26 show a decline from previous scores, a score of 20 or less on the Mini-Mental State Examination indicates significant impairment. The tool is most useful when given on an ambulatory basis to healthy people repeatedly, which allows identification of changes from baseline.
While collecting a health history from a client, the nurse notes that the client is experiencing difficulty in communicating. Which action by the nurse would be most appropriate?
Allow extra time for the client to answer any questions. When assessing a client with communication difficulties, the nurse needs to remain attentive and be patient when the person is trying to communicate. The nurse needs to take time to ask appropriate questions, pause, listen and be genuinely interested in what is being communicated. Doing so places the person at ease and encourages him to initiate communication. It also fosters self-esteem. Obtaining information from the client's significant other can help to provide additional information, but it would not be used in place of the nurse-client communication. Omitting the health history would be inappropriate. Notifying the health care provider that the client is confused is inaccurate as well as inappropriate.
A nurse is describing the concept of memory to a group of older adults at a community center. When describing how long-term memory develops, the nurse integrates knowledge of which structure as playing a role?
Hippocampi The hippocampi, part of the limbic system located within both temporal lobes, play a role in determining which memories are committed long term. The ability to retain some things and forget others is essential to intelligent behavior. Assimilating experiences and new information is a process involving memory. The hippocampi play a vital role in retaining new knowledge and preventing dissipation of the information. The reticular activating system and cerebral cortex play a role in consciousness. Proprioceptors are involved with sensations related to the body's physical state, including the relative position of different body parts and the sensation of movement.
A nurse is assessing a client and suspects that the client is experiencing disturbed thought processes. Which finding would support the nurse's suspicion? Select all that apply.
Talking to one's self Hallucinations Withdrawal from others A person experiencing disturbed thought processes or disorganized thinking interacts inappropriately with others or the environment and may have an altered perception of reality. Thinking, learning, reasoning, and remembering occur in a disorderly fashion. Manifestations of disorganized thinking may include inappropriately interacting and conversing with others, talking or gesturing to one's self, performing inappropriate activities, or exhibiting bizarre behavior. Withdrawal from others, hallucinations, and delusions are other common manifestations, especially in schizophrenia and affective disorders. Impaired thought processes involve abnormal levels of arousal, attention span deficits, and memory impairments.
Which anatomic structure coordinates consciousness, thought, memory, learning, and communication?
The cerebral cortex The cochlea is part of the inner ear. The reticular activating system is a diffuse cluster of neurons that extends from the brain stem and projects upward and throughout the spinal cord. Broca's area is the section of the brain associated with word formation and speech.
A nurse enters a client's room and finds the client completely unresponsive. The nurse would document this client's level of arousal as:
coma Arousal is a person's level of reactivity to incoming stimuli. Levels of arousal may be categorized as hypervigilant, alert, lethargic, obtunded, and comatose. Coma describes the client who is completely unresponsive to incoming stimuli. Hypervigilant means the person is acutely aware of environmental stimuli and may startle at unexpected noise; hypervigilance is often accompanied by a decreased ability to concentrate. Alert means the person is awake and fully aware of incoming stimuli. Lethargic describes the client who is not fully awake and tends to drift off to sleep when not actively stimulated. Obtunded describes the client who is difficult to arouse and when aroused is confused.
The novice nurse is frustrated conducting an assessment on a new client. The actions of the client are not making sense to the nurse, because the actions are not backing what the client is saying. The nurse suspects the client has a serious problem but the body language makes it appear there is no problem. Which concept should the nurse explore first to determine if there is a discrepancy?
culture The nurse must be aware of the cultural background of each client to better meet and provide optimal care. Each culture has its own way to express symptoms, expectations, incidence, type of disease process, and multiple aspects of treatment methodologies. The other choices may be a factor; however, culture would be a priority.
