chapter 24
What is the initial intervention the nurse should implement when helping a client diagnosed with dementia deal with paranoid delusions? explain to the client that his or her fears are unfounded observe the client in order to identify the triggers for the delusions ask that the client be prescribed medication to help manage the paranoia keep the client occupied when he or she first begins to express the delusion
observe the client in order to identify the triggers for the delusions
What is the greatest benefit support groups provide to the caregivers of clients diagnosed with dementia? provides a social outlet provides interaction with those with similar concerns provides resources for needed services provides time away from the client
provides interaction with those with similar concerns
Which client behavior should the nurse attempt to change when managing a client's tendency to wander and pace at night? insist on having the curtains left open at night request a bedtime snack of milk and cookies take a nap mid afternoon and before dinner watch television after dinner
take a nap mid afternoon and before dinner
The nurse should consider the intervention referred to as "going along with" when managing the care of which client? the adolescent who is hitting and biting because he or she was given time out for disobeying unit rules the young adult who is expressing concern about the "police being aliens" the middle-aged adult who is convinced that the electrical cords are really snakes the older widower who is worried about his wife not being able to visit because of the snow
the older widower who is worried about his wife not being able to visit because of the snow
A nurse is caring for a client diagnosed with delirium who has been brought for treatment by the client's adult child. While taking the client's history, which question would be most appropriate for the nurse to ask the client's adult child? "Has your parent taken any medications recently?" "Are you aware of your parent falling or injuring the head in any way?" "Has your parent had a recent stroke?" "Has your parent experienced any major losses recently?"
"Has your parent taken any medications recently?"
A 35-year-old client is delirious after being lost in the woods for several days and becoming severely dehydrated. At 9 p.m. the client tells the nurse to get the client's clothes because the client has to get home to the client's family. Which response by the nurse is most therapeutic? "It's time to sleep now; you can see your family in the morning." "We don't have your clothes; they are at home. You'll be going home when you recover." "Your family is fine. You need to take care of yourself now." "You're in the hospital. You did not drink for several days, but you're getting better now."
"You're in the hospital. You did not drink for several days, but you're getting better now."
Parkinson's disease is thought to be caused by which neural change? Prolonged availability of dopamine at the synaptic cleft Overproduction of dopa, which responds to treatment with its antagonist, L-dopa A loss of neurons at the basal ganglia Too many dopamine receptors in the cerebellum
A loss of neurons at the basal ganglia p461
Which would not be considered a primary goal of nursing care for a client with delirium? Achievement of self-esteem needs Protection from injury Management of confusion Meeting physiological and psychological needs
Achievement of self-esteem needs
A nurse is assessing a client diagnosed with Alzheimer's disease. As part of the assessment, the nurse asks the client to identify common objects. The nurse is assessing for what? Aphasia Apraxia Agnosia Executive functioning
Agnosia
When assessing a client with dementia, the nurse notes that the client is having difficulty identifying common items, such as a ball or book. The nurse interprets this finding as what? Aphasia Apraxia Agnosia Disturbance of executive function
Agnosia p459
The nurse is caring for a client with dementia. The client's brain images show atrophy of cerebral neurons and enlargement of the third and fourth ventricles. What is the cause of dementia in this client? Picks's disease Alzheimer's disease Vascular dementia Parkinson's disease
Alzheimer's disease
Which term is used to describe the inability to execute motor functioning, despite intact motor abilities? Apraxia Aphasia Agnosia Executive functioning
Apraxia
When giving tacrine to an elderly client, the nurse must be aware of what information? The most common side effects are headache and dizziness, so the client must be monitored for falls. Because the liver is most vulnerable to tacrine, liver function tests must be done periodically. The client will experience dry mouth and difficulty urinating. Tacrine works only in clients with late-stage dementia.
Because the liver is most vulnerable to tacrine, liver function tests must be done periodically.
An 80-year-old is brought to the clinic by the client's spouse. The client has a history of peripheral vascular disease and type 2 diabetes. The spouse states that the client hasn't seemed to be normal for the preceding few days, noting that the client has been lethargic and mildly confused at times and has been incontinent of urine. The spouse reports that the client's blood glucose levels have been elevated. The nurse considers which as the most likely explanation for the client's change in mental status? Depression related to declining health Dementia related to advancing age Delirium related to underlying medical problem Transient ischemic attacks related to vascular disease and diabetes
Delirium related to underlying medical problem
When working with the family of an older adult client recently diagnosed with vascular dementia, the nurse's primary educational concern is to what? Discuss the speed of progression of the disease's symptoms Determine ways to minimize caregiver stress Explain the onset can be related to exposure to infection Explain the medication therapy the client has been prescribed
Discuss the speed of progression of the disease's symptoms
The spouse caregiver of a client with dementia tells the nurse that the client has been agitated lately. The spouse states, "I don't know how to handle this. The client was always such a gentle person!" Which interventions should the nurse suggest? Give the client a sedative when the client begins to get agitated. Distract the client by turning on the television or watching a video. Distract the client with family photos and discuss the events pictured. Leave the client in a safe place in the house and go to another area until the client calms down.
Distract the client with family photos and discuss the events pictured.
A client with Alzheimer's disease in the intensive treatment unit repeatedly tries to go into other clients' rooms to nap during the day. The most appropriate nursing intervention for this client is what? Allowing the client to nap in an empty room Explaining to the client why this cannot be tolerated Escorting the client to the client's room for napping Suggesting that daytime napping be decreased
Escorting the client to the client's room for napping
A nurse is providing education to the care provider of a cognitively impaired client who is prescribed a cholinesterase inhibitor. Which information about medication side effects should the nurse be sure to include? Gastrointestinal (GI) symptoms Skin rashes Syncope Bruising
Gastrointestinal (GI) symptoms
A client with amnestic disorder is being evaluated for dementia. Which is a diagnostic characteristic of amnestic disorder? History and physical examination indicative of memory impairment Memory minimally decreased from usual Memory impairment limited to periods of delirium No significant problems with occupational or social functioning
History and physical examination indicative of memory impairment
A nurse is preparing a presentation for a group of staff nurses about neurocognitive disorders. When describing vascular neuorocognitive disorder, the nurse would identify which as posing the greatest risk for this disorder? Hypertension Heart disease Hyperlipidemia Diabetes
Hypertension
Which is a metabolic cause of delirium? Hypoglycemia Meningitis Encephalitis Alcohol Intoxication
Hypoglycemia
A nurse is caring for a client with delirium. The client sees a thermometer on the nurse's table and shouts, "Don't stab me!" and cowers. Which feature of delirium is this client exhibiting? Illusion Euphoria Hallucination Misinterpretation
Illusion
A client was admitted to an inpatient unit with a diagnosis of dementia. A nursing assessment and interview of the client would include what? Electroencephalogram, X-rays, blood chemistries, and skull series Intellectual ability, health history, and self-care ability Early parent-child conflict and relational patterns Assessment of deep tendon reflexes and muscle strength
Intellectual ability, health history, and self-care ability p462-463
Delirium can be differentiated from many other cognitive disorders in which way? It has as a slow onset, but if caught early it can be treated with medications. It is much less responsive to pharmacologic treatment than the other disorders. It has a rapid onset and is highly treatable if diagnosed quickly. It is characterized by a period of disorganization and confusion.
It has a rapid onset and is highly treatable if diagnosed quickly.
The client is a 68-year-old who has been showing signs of Alzheimer's disease, including visual hallucinations and disturbed behaviors. When the client was placed on antipsychotic medications, the client suffered significant adverse reactions. This could indicate that the client does not have Alzheimer's disease, but which condition? Lewy body dementia Huntington's disease Pick's disease Creutzfeldt-Jakob disease
Lewy body dementia
Which medication is not known to cause delirium? Loop diuretics Steroids Narcotics Antidepressants
Loop diuretics
A client is exhibiting signs of mild delirium such as occasional confusion about why the client is in the hospital and what day of the week it is. When developing a care plan, the nurse identifies several strategies to improve the client's cognitive function. Which intervention will be helpful to the client? Keep the television on to provide stimulation. Have someone play checkers with the client. Make up a daily calendar with the date and the times of scheduled activities. Have the client rest.
Make up a daily calendar with the date and the times of scheduled activities.
A client with a medical diagnosis of dementia of Alzheimer's type has been increasingly agitated in recent days. As a result, the nurse has identified the nursing diagnosis of "risk for injury related to agitation and confusion" and an outcome of "the client will remain free from injury." What intervention should the nurse use in order to facilitate this outcome? Apply restraints and place the client in seclusion as necessary. Monitor amount of environmental stimulation and adjust as needed. Explain to the client the relationship between agitation and injury. Set limits with the client around behavior.
Monitor amount of environmental stimulation and adjust as needed.
While reviewing the medical record of a client with moderate dementia of the Alzheimer type, a nurse notes that the client has been receiving memantine. The nurse identifies this drug as which type? Atypical antipsychotic Cholinesterase inhibitor N-methyl-D-aspartate (NMDA) receptor antagonist Benzodiazepine
N-methyl-D-aspartate (NMDA) receptor antagonist
A group of nursing students is reviewing information about delirium and its causes. The students demonstrate a need for additional review when they identify which as a cause of this medical condition? Medications Electrolyte imbalance Oxidative stress Infection
Oxidative stress
A client with dementia becomes extremely agitated shortly after being admitted to the psychiatric unit. The nurse is reluctant to use physical restraints to control the client. What is a likely reason the nurse has this reluctance? Physical restraints may cause injury to the client. Physical restraints may not be of any use in controlling the client. Physical restraints may potentially become fatal for the client. Physical restraints may increase the client's agitation.
Physical restraints may increase the client's agitation. pp463-465
A older adult client develops delirium secondary to an infection. Which would be the most likely cause? Pneumonia Cellulitis Low platelet count Appendicitis
Pneumonia p453
The client has advanced Alzheimer's disease and becomes confused at mealtimes. The client has agnosia, apraxia, and disturbed executive functioning. Which is the most appropriate nursing intervention? Provide the client with a tray but encourage the client to open the client's own packages. Provide the client with a tray, opening containers for the client. Ask the client what the client would like from the buffet and give the client finger foods. Have the client eat in the client's room to avoid distractions while eating.
Provide the client with a tray, opening containers for the client.
A client is in the mild stage of dementia due to Alzheimer's disease. Which intervention would be most appropriate? Providing emotional support and gentle reminders Offering nourishing finger foods to help maintain the client's nutritional status Advocating for the client to be transitioned to a care home Suggesting new activities for the client and family to do together
Providing emotional support and gentle reminders
A care aide has rung the call light for assistance while providing a client's twice-weekly bath because the client became agitated and aggressive while being undressed. Knowing that the client has a diagnosis of dementia of Alzheimer's type and is prone to agitation, which measure may help in preventing this client's agitation? Decreasing the frequency of the client's baths from two times to one time per week Reminding the client multiple times that he or she will be soon having a bath Reinforcing the facility's zero-tolerance policy for aggressive behavior Providing all of the client's daily medications early on the day of a scheduled bath
Reminding the client multiple times that he or she will be soon having a bath
A nurse's aide has rung the call light for assistance while providing a client's twice-weekly bath because the client became agitated and aggressive while being undressed. Knowing that the client has a diagnosis of Alzheimer's disease and is prone to agitation, which measure may help in preventing this client's agitation? Decreasing the frequency of the client's baths from two times to one time per week Reminding the client multiple times that he or she will be soon having a bath Reinforcing the facility's zero-tolerance policy for aggressive behavior Providing all of the client's daily medications early on the day of a scheduled bath
Reminding the client multiple times that he or she will be soon having a bath
Which nursing diagnosis would be the priority for the client experiencing acute delirium? Acute confusion related to delirium of known/unknown etiology Fall precautions related to acute confusion Risk for injury related to confusion and cognitive deficits Risk for self-mutilation related to confusion and cognitive deficits
Risk for injury related to confusion and cognitive deficits
Which would be the priority goal for a client with dementia? Safety Nutrition Physical stability Sleep
Safety
Which can be identified as a hallmark symptom of dementia? Short-term memory loss Long-term memory affected most This class of disorders does not involve memory loss Clients with these disorders tend to confabulate
Short-term memory loss
The nurse receives a report that a 75-year-old client is recovering from surgery. During the shift, the nurse notes that the client is forgetful and restless. Several times, the client calls the nurse the name of the client's daughter. The nurse interprets this behavior as what? Normal for the first postoperative day Normal, given the client's age Signs of early Alzheimer's disease Signs of delirium
Signs of delirium p452-453
The client is 42 years old, married, and has two children, ages 16 and 18. The client is also caring for the client's parent, who is in the late stages of Alzheimer's disease. The nurse would want to assess the client for what? Early signs of Alzheimer's disease Likelihood to engage in elder abuse Signs of stress Signs of dominance
Signs of stress p470-471
The nurse is caring for a client with delirium. Which interventions may help manage this client? Select all that apply. Speak in simple sentences. Encourage the client to follow a regular routine. Use matter-of-fact approach when assuming tasks the client can no longer perform. Provide orienting verbal cues when talking with the client. Allow adequate time for the client to comprehend and respond.
Speak in simple sentences. Provide orienting verbal cues when talking with the client. Allow adequate time for the client to comprehend and respond. p457
The psychiatric nurse documents that the cognitively impaired client is exhibiting "confabulation" when observed doing what? Telling other clients that the client "was a dairy farmer" when the client actually ran a small grocery store Telling the staff repeatedly that "my name is George and I'm hungry" Pacing nervously and resisting the staff's request to "get ready for bed" Asking where the cats are when told it's "raining cats and dogs"
Telling other clients that the client "was a dairy farmer" when the client actually ran a small grocery store
The client has early Alzheimer's disease. When asked about family history, the client relates that the client has two children who are both grown and who visit the client around the holidays each year. The nurse subsequently discovers that the client has one child who is currently assigned overseas and who has not been home for 2 years. Which would best describe the client's behavior? The client is confabulating, most likely to cover for memory deficit. The client is confused about the client's children and needs refocusing. The client demonstrates aphasia when discussing the client's children. The client is showing signs of agnosia in that the client is unable to name the client's children.
The client is confabulating, most likely to cover for memory deficit. p465
The nurse is interviewing a 50-year-old with a suspected cognitive disorder. The client has a long history of alcoholism. When the nurse asks if the client is employed, the client replies that the client is currently employed as a conductor on a national railway system. The client's spouse takes the nurse aside and informs the nurse that the client hasn't worked for several years and never worked for the railway. The nurse attributes the client's answer to which explanation? The client is ashamed that the client is unemployed and is trying to cover for it. The client may have Alzheimer's disease. The client may be going through alcohol withdrawal. The client may have Korsakoff's syndrome.
The client may have Korsakoff's syndrome.
The nurse asks a client to pretend the client is brushing the client's teeth. The client is unable to perform the action. Upon examination, the nurse finds that the client possesses intact motor abilities. What can this problem be documented as? The client may have agnosia. The client may have aphasia. The client may have apraxia. The client may have disturbed executive function.
The client may have apraxia.
A 65-year-old has been admitted to the intensive care unit following surgical resection of the bowel. The client has developed a fever. Which additional signs indicate the client has developed delirium? The client cannot brush the client's teeth. The client identifies the client's fork as a spoon. The client removes the client's surgical bandage and begins picking at the sheets. The client has trouble remembering the client's birth date.
The client removes the client's surgical bandage and begins picking at the sheets.
The diagnosis of delirium is supported when the nurse notes which in the client? The is convinced that the client sees "hundreds" of bugs and is not always oriented to time and place The client repeatedly asks where the client is and attempts to drink the water in a flower vase The client spends much of the day sleeping in the dayroom and usually denies being hungry The client responds to most assessment questions with "I don't know" and appears apathetic
The is convinced that the client sees "hundreds" of bugs and is not always oriented to time and place
Major goals for the nursing care of clients with dementia should include what? The client will be safe, be physiologically stable, and have infrequent episodes of agitation. The client will be safe and eat appropriately. The client will be physically stable, maintain normal body weight, and be safe. The client will have no self-harm behaviors and maintain sleep and appetite.
The client will be safe, be physiologically stable, and have infrequent episodes of agitation.
A group of friends have arrived at the hospital to visit a client recently diagnosed with delirium. The nurse tells the friends they can visit with the client one at a time. What is the likely reason for the nurse to give this instruction? The nurse wants to ensure the client's safety. The nurse wants to prevent increasing the client's confusion. The nurse wants the client to demonstrate good orientation. The nurse wants the client to maintain an adequate balance of activity and rest.
The nurse wants to prevent increasing the client's confusion. p457
A nurse is caring for a client with delirium. The nurse assesses the client's activities of daily living on a daily basis. What is the most likely reason for assessing these so frequently? To ensure the client is involved in therapy To ensure the client establishes a daily routine To assess the prognosis of the client after therapy To assess for fluctuation in the client's capabilities
To assess for fluctuation in the client's capabilities
A nurse is studying the medical chart of a client with delirium. The nurse finds that the client was given haloperidol. What would be the most likely reason for administering this drug to the client? To sedate the client To decrease agitation To improve dietary intake To minimize the effects of alcohol withdrawal
To decrease agitation
The nurse is working with the family of a client who is newly diagnosed with Alzheimer's type dementia. Which suggestion would be effective for assisting the family members in daily orienting of their family member when the client returns home? Provide a flexible schedule and change the activities each day. Use daily newspapers, calendars, and a set routine. Read to the client for long periods at a time. Use a daily current events quiz, making sure that the client participates.
Use daily newspapers, calendars, and a set routine.
To manage voiding issues, such as incontinence, male clients diagnosed with dementia would best be managed by what? Use of disposable, adult diapers Indwelling catheters Intermittent catheterization Condom catheter
Use of disposable, adult diapers
When assessing a client with dementia, a nurse identifies that the client is experiencing hallucinations. Based on the nurse's understanding of this disorder, which type of hallucination would the nurse expect as most common? Auditory Visual Gustatory Olfactory
Visual
Which type of hallucination most commonly occurs in clients diagnosed with dementia? Visual Auditory Gustatory Olfactory
Visual
An older adult with no significant medical history is admitted to the hospital through the emergency department after hitting the client's head during a fall and fracturing the humerus. The client does not require surgery and will probably be discharged the following day. Should the nurse be concerned about delirium? No, because the client does not have an underlying disease process No, because the client will not be hospitalized long enough to develop delirium Yes, because of the head injury and medication Yes, because the client is in an unfamiliar environment and overstimulated
Yes, because of the head injury and medication