CHAPTER 9 DELIRIUM, DEMENTIA, HIV, AND AMNESTIC DISORDERS

8. After dementia has been ruled out, a client is diagnosed with pseudodementia (depression). Which of the following client symptoms would support this diagnosis? Select all that apply. 1. Slow progression of symptoms. 2. Impaired attention and concentration. 3. Diminished appetite. 4. Symptoms diminish as the day progresses. 5. Oriented to time and place with no wandering.

. A client's symptoms may mimic dementia. This masquerade is sometimes referred to as pseudo- dementia (depression). A battery of psychologi- cal tests may be ordered to differentiate between the two diagnoses. 1. A slow progression of symptoms is associated with dementia. A rapid progression is associ- ated with pseudodementia (depression). 2. Impaired attention and concentration is asso- ciated with dementia, whereas intact attention and concentration is a characteristic of pseu- dodementia (depression). ✅3. Diminished appetite is a symptom of pseudodementia (depression). Appetite in clients diagnosed with dementia remains unchanged. Also, clients diagnosed with dementia appear unconcerned about their disorder, whereas a client diagnosed with pseudodementia (depression) communi- cates severe distress regarding this fright- ening development. ✅4. As the day progresses, a client diagnosed with pseudodementia (depression) experi- ences a diminished severity of symptoms, whereas a client diagnosed with dementia experiences an increase in the severity of symptoms. ✅5. A client diagnosed with pseudodementia (depression) does not become lost in familiar surroundings and does not have to be oriented to time and place. A client diagnosed with dementia often seems lost in what should be familiar surroundings and is in need of continual orientation to time and place TEST-TAKING HINT: The test taker must under- stand that cognitive symptoms of depression may mimic dementia. To answer this question cor- rectly, the test taker must differentiate between the symptoms of dementia and pseudodementia (depression).

13. An 80-year-old client admitted to the emergency department is experiencing fever, dysuria, and urinary frequency. The client is combative and seeing things others do not see. Which nursing diagnosis reflects this client's problem? 1. Disturbed sensory perceptions R / T infection AEB visual hallucinations. 2. Risk for violence: self-directed R / T disorientation. 3. Self-care deficit R / T decreased perceived need AEB disheveled appearance. 4. Social isolation R / T decreased self-esteem.

. Deliriumisdefinedasastateofmentalconfusion or excitement characterized by disorientation for time and place, often with hallucinations, inco- herent speech, and a continual state of aimless physical activity. ✅1. The nursing diagnosis of disturbed senso- ry perception is defined as a change in the amount of patterning of incoming internal or external stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli. This client is experiencing symptoms of a uri- nary tract infection (UTI). The client's combativeness and visual hallucinations, caused by septicemia secondary to the UTI, are indicative of a disturbed sensory perception. In an elderly client, a UTI, if untreated, often leads to symptoms of delirium. 2. The nursing diagnosis of risk for violence: self-directed is defined as behaviors in which a client demonstrates that he or she can be physically, emotionally, or sexually harmful to self. No information is presented in the ques- tion that indicates this client is at risk for self-directed violence. Combativeness may place the client at risk for violence directed toward others. 3. The nursing diagnosis of self-care deficit is defined as the impaired ability to perform or complete activities of daily living independ- ently. No information is presented in the question that indicates this client is experi- encing a self-care deficit. 4. The nursing diagnosis of social isolation is defined as aloneness experienced by the individual and perceived as imposed by others and as a negative or threatened state. No information is presented in the question that indicates TEST-TAKING HINT: To answer this question cor- rectly, the test taker must pair the symptoms presented in the question with the nursing diag- nosis that reflects the client's problem.

6. On a 24-hour assessment, the nurse documents that a client diagnosed with Alzheimer's disease presents with aphasia. Which client behavior supports this finding? 1. The client is sad and has no ability to experience pleasure. 2. The client is extremely emaciated and appears to be wasting away. 3. The client is having difficulty in forming words. 4. The client is no longer able to speak.

1. Anhedonia, not aphasia, is the term used when an individual is sad and has no ability to experience or even imagine any pleasant emotion. 2. Cachexia, not aphasia, is the term used when an individual is in ill health and experiencing malnutrition and wasting. This may occur in many chronic diseases, certain malignancies, and advanced pulmonary tuberculosis. ✅3. Aphasia is the term used when an individual is having difficulty communicating through speech, writing, or signs. This is often caused by dysfunction of brain centers. Aphasia is a cardinal symptom observed in Alzheimer's disease. 4. Aphonia, not aphasia, is the term used when an individual is no longer able to speak. This may result from chronic laryngitis, laryngeal nerve damage, brain lesions, or psychiatric causes, such as hysteria. TEST-TAKING HINT: The test taker needs to understand the term "aphasia" and be able to recognize the client symptoms that reflect this problem.

5. Which statement best explains the pathophysiology associated with Parkinson's disease? 1. The disease results from atrophy in the frontal and temporal lobes. 2. A transmissible agent known as a "slow virus" or prion is associated with this disease. 3. A loss of nerve cells located in the substantia nigra is associated with this disease. 4. The disease results from damage in the basal ganglia and the cerebral cortex.

1. Atrophy in the frontal and temporal lobe is associated with Pick's, not Parkinson's, disease. 2. A transmissible agent known as a "slow virus" or prion is associated with Creutzfeldt-Jakob, not Parkinson's, disease. ✅3.In Parkinson's disease, there is a loss of nerve cells located in the substantia nigra. Diminished dopamine activity results in involuntary muscle movements, slowness, and rigidity. Tremor in the upper extremi- ties is characteristic. Dementia, which closely resembles that of Alzheimer's disease, is observed in 60% of clients with Parkinson's disease. 4. Damage in the basal ganglia and the cerebral cortex is associated with Huntington's, not Parkinson's, disease. TEST-TAKING HINT: The test taker must under- stand the pathophysiology of Parkinson's disease to answer this question.

17. A client diagnosed with dementia states, "I can't believe it's the 4th of July and it's snow- ing outside." Which is the nurse's most appropriate response? 1. "What makes you think it's the 4th of July?" 2. "How can it be July in winter?" 3. "Today is March 12, 2007. Look, your lunch is ready." 4. "I'll check to see if it's time for your PRN haloperidol (Haldol)."

1. Questioning the client's perception shows contempt for the client's ideas or behaviors. Asking a client to provide reasons for thoughts can be intimidating and implies that the client must defend his or her behavior or feelings. 2. Challenging the client belittles the client and discourages further interactions. ✅3. Orienting the client to person, place, and time, as necessary, refocuses the client to the here and now. Casually reminding the client of a noon meal redirects the client in a manner that is considerate and respectful. It is imperative to preserve the client's self-esteem. 4. PRN medication at this time would do noth- ing to reorient the client to the here and now. PRN haloperidol (Haldol) would be appro- priate if the client were exhibiting agitation or uncontrolled behavior, not confusion and disorientation. TEST-TAKING HINT: When clients are diagnosed with dementia, it is important to preserve self- esteem. These clients do not have the capacity to correct impaired orientation. When the nurse challenges the client's thought processes, as in "1" and "2," the client's self-esteem is decreased. Medicating a client, as in "4," without pursuing other avenues of problem solving is inappropriate.

16. A client who is delirious yells out to the nurse, "You are an idiot, get me your supervisor." Which is the best nursing response in this situation? 1. "You need to calm down and listen to what I'm saying." 2. "You're very upset, I'll call my supervisor." 3. "You're going through a difficult time. I'll stay with you." 4. "Why do you feel that my calling the supervisor will solve anything?"

1. Telling a client who is experiencing delirium to calm down and listen is unrealistic. The client's reasoning ability and goal-directed behavior are impaired, and the client is unable to calm down or listen. 2. Acknowledging that the client is upset pro- motes understanding and trust, but the nurse in this situation can address the client's symptoms appropriately by frequent orientation to reality without calling the supervisor. ✅3. Empathetically expressing understanding of the client's situation promotes trust and may have a calming effect on the client. Delirious or confused clients may be at high risk for injury and should be moni- tored closely. 4. Requesting an explanation from a client regarding reasons for feelings, thoughts, or behaviors in any situation, especially a situa- tion in which a client is experiencing deliri- um, is nontherapeutic. TEST-TAKING HINT: The test taker must under- stand that in the situation presented the client is in need of empathy, support, and close obser- vation. Only "3" provides these interventions. It is nontherapeutic to request an explanation by asking the client "why," which eliminates "4" immediately. Also, if one part of the answer is incor

12. A client newly diagnosed with vascular dementia isolates self because of consistently poor role performance and increasing loss of independent functioning. Which nursing diagnosis reflects this client's problem? 1. Disturbed thought processes R / T decreased cerebral circulation AEB disorientation. 2. Risk for injury R / T poor role performance AEB decreased functioning. 3. Disturbed body image R / T loss of independent functioning AEB tearful, sad affect. 4. Low self-esteem R / T loss of independent functioning AEB social isolation.

1. The nursing diagnosis of disturbed thought processes is defined as the disruption of cog- nitive operations and activities. Although clients diagnosed with vascular dementia may experience disturbed thought processes, the symptoms of isolation, poor role performance, and loss of independent functioning are not reflective of this nursing diagnosis. 2. The nursing diagnosis of risk for injury is defined as the result of interaction of (internal or external) environmental condi- tions with the client's adaptive and defense resources. Although clients diagnosed with vascular dementia are at risk for injury, the symptoms noted in the question are not reflective of this nursing diagnosis. Also, a correctly written "risk for" nursing diagnosis does not contain an "AEB" statement. 3. The nursing diagnosis of disturbed body image is defined as confusion in mental picture of one's physical self. There is no information noted in the question that indi- cates this client is experiencing a disturbed body image. ✅4. The nursing diagnosis of low self-esteem is defined as a negative self-evaluation or feelings about self or self-capabilities. This client is experiencing social isolation which is evidence of low self-esteem. Poor role performance and loss of independent functioning exacerbate this problem further. TEST-TAKING HINT: To answer this question cor- rectly, the test taker must pair the symptoms presented in the question with the nursing diag- nosis that reflects the client's problem. Because the nursing diagnosis in "2" is incorrectly writ- ten, the test taker can eliminate this answer choice immediately.

21. A client diagnosed with primary dementia has a nursing diagnosis of altered thought process R/T disorientation and confusion. Which nursing intervention should be implemented first? 1. Use tranquilizing medications and soft restraints. 2. Continually orient client to reality and surroundings. 3. Assess client's level of disorientation and confusion. 4. Remove potentially harmful objects from the client's room.

1. Using tranquilizing medications and soft restraints might be a priority intervention if the client were a danger to self or others; however, there is no mention of violent behavior in the question. The least restrictive measures should be employed initially. 2. It is necessary first to assess the client's level of disorientation and confusion before initiating other interventions. Continually reorienting this client would not be an effec- tive intervention because of the irreversible nature of the client's diagnosis. ✅3. Assessing the client's level of disorienta- tion and confusion should be the first nursing intervention. Assessment of a client diagnosed with dementia is necessary to formulate a plan of care and to determine specific interventions and requirements for safety. 4. Assessing the client's level of disorientation and confusion is necessary to determine spe- cific requirements for safety. The nurse then may remove potentially harmful objects from the client's room, if needed. TEST-TAKING HINT: The test taker needs to understand that assessment, the first step in the nursing process, is the initial step in determining an appropriate plan of care for a client.

4. A client diagnosed with Alzheimer's disease is displaying signs and symptoms of anxiety, fear, and paranoia. An alteration in which area of the brain is responsible for these signs and symptoms? 1. Frontal lobe. 2. Parietal lobe. 3. Hippocampus. 4. Amygdala.

1. When there is an alteration in the frontal lobe, the nurse should expect to see impaired reasoning ability. Because of this, clients are unable to solve problems and perform familiar tasks. Symptoms of anxiety, fear, and paranoia are not associated with this alteration. 2. When there is an alteration in the parietal lobe, the nurse should expect to see impaired orientation ability and impaired visuospatial skills. Because of this, clients are unable to maintain orientation to their environment. Symptoms of anxiety, fear, and paranoia are not associated with this alteration. 3. When there is an alteration in the hippocam- pus, the nurse should expect to see impaired memory. Because of this, clients initially experience short-term memory loss and later are unable to form new memories. Symptoms of anxiety, fear, and paranoia are not associat- ed with this alteration. ✅4. When there is an alteration in the amygdala, the nurse should expect to see impaired emotions—depression, anxiety, fear, personality changes, apathy, and paranoia. The amygdala is a mass of gray matter in the anterior portion of the tem- poral lobe. It also is believed to play an important role in arousal. TEST-TAKING HINT: To answer this question cor- rectly, the test taker must be familiar with brain structure and function and the symptoms caused by alterations in these structures.

24. On discharge, a client diagnosed with dementia is prescribed donepezil hydrochloride (Aricept). Which would the nurse include in a teaching plan for the client's family? 1. "Donepezil is a sedative/hypnotic used for short-term treatment of insomnia." 2. "Donepezil is an Alzheimer's treatment used for mild-to-moderate dementia." 3. "Donepezil is an antipsychotic used for clients diagnosed with dementia." 4. "Donepezil is an antianxiety agent used for clients diagnosed with dementia."

1.Although short-term treatment for insomnia may be prescribed for a client diagnosed with dementia, donepezil hydrochloride (Aricept) is not a sedative/hypnotic, and it is not used for insomnia. ✅2. Donepezil hydrochloride (Aricept) is an Alzheimer's treatment used for mild-to- moderate dementia. A decrease in cholin- ergic function may be the cause of Alzheimer's disease, and donepezil is a cholinesterase inhibitor. This drug exerts its effect by enhancing cholinergic function by increasing the level of acetylcholine. 3. Antipsychotics are sometimes used for the symptoms of Alzheimer's disease, but donepezil hydrochloride (Aricept) is not an antipsychotic drug, and it is not used in this context. 4. Although clients diagnosed with Alzheimer's disease may need anxiolytic medications to decrease anxiety, donepezil hydrochloride (Aricept) is not an anxiolytic and would not be used in this context. TEST-TAKING HINT: The test taker must know the classification and use of the drug donepezil hydrochloride (Aricept) to answer this question correctly.

18. In writing a plan of care for a client diagnosed with dementia, the nurse would consid- er which tertiary prevention intervention? 1. Administer mini-mental status examination and document. 2. Maintain routine to prevent further confusion and disorientation. 3. Obtain occupational therapy consultation to slow further physical decline. 4. Encourage socialization to prevent isolation and further confusion.

1.Primary prevention is a true prevention and pre- cedes disease or dysfunction. Secondary prevention focuses on individuals who are experiencing health problems or illnesses. Tertiary prevention occurs when a defect or disability is permanent and irreversible, with the focus on rehabilitation. 1. A mini-mental status examination given to determine decline in mental functioning is an assessment tool that helps the nurse determine a client's cognitive function. Because the client is currently diagnosed with dementia, this action is considered a secondary, not tertiary, prevention intervention. 2. Maintaining a routine for a client diagnosed with dementia who is already confused and disoriented addresses a condition that the client is currently experiencing. This action is considered a secondary, not tertiary, preven- tion intervention. ✅3. Obtaining an occupational therapy consul- tation to slow further physical decline would be considered a tertiary prevention intervention. Tertiary prevention is health care that is directed toward reduction of the residual effects associated with severe or chronic physical or mental illness. 4. A client diagnosed with dementia can have problems with socialization, isolation, and confusion. Because this is a current client problem, this intervention would be consid- ered a secondary, not tertiary, prevention intervention. TEST-TAKING HINT: To answer this question, the test taker needs to understand and differentiate nursing actions that occur in primary, secondary, and tertiary prevention.

15. A nursing diagnosis of self-care deficit R/T memory loss AEB inability to fulfill activ- ities of daily living (ADLs) is assigned to a client diagnosed with Alzheimer's disease. Which is an appropriate short-term outcome for this individual? 1. The client participates in ADLs with assistance by discharge. 2. The client accomplishes ADLs without assistance after discharge. 3. By time of discharge, the client will exhibit feelings of self-worth. 4. The client will not experience physical injury.

All outcomes must be client-centered, realistic, specific, positive, and measurable, and contain a timeframe. ✅1. The client participating in activities of daily living (ADLs) is a short-term outcome related to the nursing diagnosis of self-care deficit. This outcome meets all the criteria listed in the rationale. It is specific (ADLs), positive (participate), measurable (by discharge), realistic, and client-centered. 2. Alzheimer's disease is an irreversible dementia. The client accomplishing ADLs without assistance after discharge is not a realistic out- come for this client. 3. The client exhibiting feelings of self-worth does not relate to the nursing diagnosis of self-care deficit. 4. Maintaining physical safety is an important outcome. However, this outcome is not measurable and does not relate to the nursing diagnosis of self-care deficit. TEST-TAKING HINT: To answer this question cor- rectly, the test taker needs to pair outcomes with the stated nursing diagnosis. Outcomes need to be realistic, and because of the chronic and irre- versible nature of the diagnosis of Alzheimer's disease, "2" can be eliminated immediately.

1. In accordance with the DSM-IV-TR, which of the following chronic or transient med- ical conditions are associated with amnestic disorders? Select all that apply. 1. Cerebral anoxia. 2. Cardiac arrhythmias. 3. Migraine. 4. Psoriasis. 5. Cerebrovascular disease

Amnestic disorders are characterized by an inability to learn new information and an inability to recall previously learned information. These disorders differ from dementia in that there is no impairment in abstract thinking or judgment and no personality change. ✅1. Cerebral anoxia is an oxygen-depriving condition, which can result in an amnestic disorder. ✅2. Cardiac arrhythmias can cause cerebral anoxia, which can result in an amnestic disorder. ✅3. Migraine headaches may result in symp toms including, but not limited to, mood changes, depression, fatigue, and occasionally amnesia. 4. Psoriasis is a common chronic disease of the skin whose sequelae do not include any form of amnesia. ✅5. Cerebrovascular disease can cause cerebral anoxia, which may result in an amnestic disorder. TEST-TAKING HINT: The test taker must under- stand which medical conditions are associated with amnestic disorders to answer this question correctly

25. An emaciated client diagnosed with delirium is experiencing sleeplessness, auditory hallucinations, and vertigo. Meclizine (Antivert) has been prescribed. Which client response supports the effectiveness of this medication? 1. The client no longer hears voices. 2. The client sleeps through the night. 3. The client maintains balance during ambulation. 4. The client has an improved appetite.

Meclizine (Antivert) is a medication used for the management of motion sickness and vertigo. 1. Meclizine (Antivert) is used to improve vertigo, not auditory hallucinations. An antipsychotic medication would be indicated for this symptom. 2. Meclizine (Antivert) is used to improve verti- go, not sleep problems. A benzodiazepine would be an appropriate short-term interven- tion to improve sleep. 3. Meclizine (Antivert) has central anti- cholinergic, central nervous system depressant, and antihistaminic properties and is used to improve vertigo. Maintaining balance is an indication that vertigo has improved. 4. Meclizine (Antivert) is used to improve vertigo, not anorexia. An appetite stimulant would be indicated for this symptom. TEST-TAKING HINT: To answer this question correct- ly, the test taker must recognize meclizine (Antivert) as a medication used for dizziness and vertigo.

23. A family member of a client experiencing dementia and being treated for normal- pressure hydrocephalus asks the nurse, "Is my father's dementia reversible?" Which nursing response indicates understanding of primary and secondary dementia? 1. "Treatment sometimes can reverse secondary dementia." 2. "Unfortunately, primary dementia is not reversible." 3. "Unfortunately, secondary dementia is not reversible." 4. "Treatment sometimes can reverse primary dementia."

Normal-pressure hydrocephalus (NPH) occurs when there is an increased volume of cere- brospinal fluid (CSF) in the closed system of the brain and spinal cord. NPH was first described in 1965 and has a trio of characteristic symptoms: dementia, gait disturbance, and urinary inconti- nence. Head trauma and infection sometimes can cause NPH; however, in most cases, the etiology is unknown. Dementia is secondary to NPH. ✅1. Dementia that is secondary to NPH is sometimes reversible when the CSF pressure is relieved. A neurosurgical procedure that shunts the excess CSF from the brain to the abdominal cavity reduces the pres- sure on brain cells. In contrast to primary dementia from Pick's disease or Alzheimer's disease, in which brain cells actually die, brain cells affected by NPH regain function in more than 50% of cases. 2. Primary dementia is irreversible; however, the client in the question has been diagnosed with NPH. Dementia that occurs as a result of NPH is considered a secondary, not primary, dementia and is reversible. 3. If treated, dementia that is secondary to other conditions, such as NPH, depression, or drug toxicity, may be reversed in some cases. The underlying pathology of the dementia determines the reversibility. 4. Primary dementia is irreversible. Alzheimer's disease, Parkinson's disease, and Huntington's chorea are a few examples of primary demen- tias that are progressive and irreversible. TEST-TAKING HINT: To answer this question, the test taker must differentiate between primary and secondary dementias.

3. The physician tells family members that their father, who is experiencing confusion and memory loss, has a reversible form of dementia. Which is the likely cause of this disorder? 1. Multiple sclerosis. 2. Multiple small brain infarcts. 3. Electrolyte imbalance. 4. HIV disease.

Primary dementia runs a progressive, irre- versible course. True secondary or temporary dementia occurs in only a few cases and can be reversible. The reversibility of secondary dementia is a function of the timeliness of interventions that address the underlying pathology. 1. Multiple sclerosis is a chronic, not reversible, autoimmune inflammatory disease of the cen- tral nervous system. Because this underlying condition is irreversible, the accompanying dementia likewise would be irreversible. 2. Multiple small brain infarcts result from a failure of blood supply to the cerebral area. Multiple small brain infarcts cause permanent and irreversible necrosis, leading to primary vascular dementia. ✅3. Imbalance in electrolytes can have cata- strophic effects on the body, including confusion, memory loss, and disorientation. The secondary dementia symptoms are reversible with the restoration of the electrolyte balance. 4. HIV-associated primary dementia is a neu- ropathological syndrome, possibly caused by chronic HIV encephalitis and myelitis. This syndrome is manifested by cognitive and behav- ioral symptoms, particularly confusion. Because this underlying condition is irreversible, the accompanying dementia likewise is irreversible. TEST-TAKING HINT: To answer this question cor- rectly, the test taker should recognize that demen- tia can be primary or secondary. Chronic disorders produce dementia that is more apt to be perma- nent. Recognizing the chronic nature of "1," "2," and "4" can eliminate these answer choices.

19. In writing a plan of care for a client diagnosed with dementia, the nurse considers which of the following secondary prevention interventions? Select all that apply. 1. Reinforce speech with nonverbal techniques by pointing to and touching items. 2. Keep surroundings simple by reducing clutter. 3. Offer family ethics consultation or hospice assistance if appropriate. 4. Place large, visible clock and calendar in client's room. 5. Talk to family members about genetic predisposition regarding dementia.

Primary prevention is a true prevention and pre- cedes disease or dysfunction. Secondary preven- tion focuses on individuals who are experiencing health problems or illnesses. Tertiary prevention attempts to reduce the residual effects when a defect or disability is permanent and irreversible. ✅1. Because the client is experiencing alter- ations in cognition, reinforcing speech with nonverbal techniques, such as point- ing to and touching items, is a secondary prevention intervention. 2. Keeping surroundings simple by reducing clutter would prevent injury if a client's gait is impaired. Nothing in the question indicates that this client has an impaired gait. 3. Offering family ethics consultation or hospice assistance would be a tertiary, not secondary, prevention intervention. ✅4. Placing a large, visible clock and calendar in the client's room addresses the client's current confusion. Because this addresses the client's actual problem of disorienta- tion, this intervention would be consid- ered secondary prevention. 5. Talking to family members about their genet- ic predisposition to dementia is a primary, not secondary, prevention intervention. TEST-TAKING HINT: To answer this question, the test taker needs to understand and differentiate the nursing actions that occur in primary, secondary, and tertiary prevention.

7. A client newly diagnosed with Alzheimer's disease was admitted 72 hours ago. The client states, "Last night I went on a wonderful dinner cruise." Which type of commu- nication is this client expressing, and what is the underlying reason for its use? 1. The client is using confabulation to achieve secondary gains. 2. The client is using confabulation to protect the ego. 3. The client is using perseveration to divert attention. 4. The client is using perseveration to maintain self-esteem.

The client in the question is using confabula- tion. Confabulation is the creation of imaginary events to fill in memory gaps. 1. Although the client is using confabulation, the underlying reason is to protect the ego by maintaining self-esteem, not to achieve secondary gains. ✅2. Clients diagnosed with Alzheimer's dis- ease use confabulation to create imaginary events to fill in memory gaps. This "hiding" is actually a form of denial, which is a protective ego defense mechanism used to maintain self-esteem and avoid losing one's place in the world. 3. The client in the question is using confabula- tion, not perseveration. A client who exhibits perseveration persistently repeats the same word or idea in response to different questions. 4. Although maintaining self-esteem is important for individuals diagnosed with Alzheimer's disease, the use of perseveration does not increase self-esteem. The client in the question is using confabulation, not perseveration. A client who exhibits perseveration persistently repeats the same word or idea in response to different questions. TEST-TAKING HINT: To answer this question cor- rectly, the test taker first must understand the meaning of the terms "confabulation" and "perseveration." Also, the test taker must note that when two concepts are presented in answer choices, both concepts must be correct. Knowing this, the test taker can eliminate "1" and "4" immediately.

9. A client presents in the emergency department with an acute decrease in cognitive ability. The nurse's assessment should include which of the following? Select all that apply. 1. Family history and a mini-mental status examination. 2. Laboratory tests and vital signs. 3. Toxicology screen for illegal substances. 4. Open-ended questions to obtain information. 5. Familiarizing the client with the milieu.

✅1. A nursing assessment of a client with an acute decrease in cognitive ability should include a family history, such as specific mental and physical changes, and the age at which the changes began. If the client is unable to relate this information, the data should be obtained from family or friends. A nurse may administer a mini- mental status examination, which is a commonly used assessment tool to quanti- fy an individual's cognitive ability. It assesses orientation, registration, attention and calculation, and language. Scoring is from 0 to 30, with 30 indicating intact cognition. ✅2. A nursing assessment should include vital signs and the results of diagnostic lab tests ordered by the physician. Blood and urine samples should be obtained to test for var- ious infections, hepatic and renal function, diabetes or hyperglycemia, electrolyte imbalances, and the presence of toxic substances. Vital signs are measured to assess for physiological problems and to establish a baseline. ✅3. A nursing assessment should include the results of a toxicology report ordered by the physician. The nurse also should understand that even with a negative report, delirium might persist after substance intoxication or substance withdrawal. 4. To assess a client effectively, it is essential for a nurse to use good communication skills. To obtain important facts and specific details, close-ended, not open-ended, questions can be effective in focusing a client with an acute decrease in cognition. 5. Familiarizing the client with the milieu is important; however, this nursing action is an intervention, not an assessment TEST-TAKING HINT: It is important for the test taker to note keywords in the question, such as "assessment." Answer "5" can be eliminated immediately because it is an intervention, not an assessment.

20. In working with clients with late-stage Alzheimer'sdementia,which is a priority inter- vention? 1. Assist the client to consume fluids and food to prevent electrolyte imbalance. 2. Reorient the client to place and time frequently to reduce confusion and fear. 3. Encourage the client to participate in own activities of daily living to promote self- esteem. 4. Assist with ambulation to avoid injury from falls.

✅1. Nutritional deficits are common among clients diagnosed with late-stage Alzheimer's dementia. These clients must be assisted to consume fluids and food to prevent electrolyte imbalance. Meeting this physical need would be prioritized over meeting psychological needs. 2. Clients diagnosed with late-stage Alzheimer's dementia may have severely impaired speech and language, may no longer recognize family members, and may be socially withdrawn and unaware of environment and surroundings. Reorientation would not be an effective inter- vention at this time. 3. Clients diagnosed with late-stage Alzheimer's dementia are most commonly bedridden and aphasic. At this stage, caregivers need to com- plete the client's activities of daily living. Promoting dignity and comfort, not self- esteem, would be a priority intervention in this case. 4.It is common for clients diagnosed with late- stage Alzheimer's dementia to be confined to a wheelchair or bed; ambulation and the need for assistance would not be expected. TEST-TAKING TIP: The test taker needs to recognize that nursing interventions need to be realistic. This eliminates "2" and "3" immediately. Because of the chronic nature and irreversibility of the client's disorder, these interventions expect more than this client realistically can achieve.

14. A client diagnosed with dementia has a nursing diagnosis of risk for injury R / T extreme psychomotor agitation. Which would be an appropriate short-term outcome related to this problem? 1. The client will remain free from injury during this shift. 2. The client will ask the nurse for assistance when becoming confused. 3. The client will verbalize staff appreciation by day 3. 4. The client will demonstrate ability to perform activities of daily living on discharge.

✅1. Remaining free from injury is an appro- priate short-term outcome for the nursing diagnosis of risk for injury. This short- term outcome meets all the criteria listed in the rationale. It is specific (injury), pos- itive (free from), measurable (during this shift), realistic, and client-centered. 2. This outcome does not include a timeframe, and so it is not measurable. 3. Verbalizing staff appreciation does not relate to the nursing diagnosis of risk for injury. 4. Demonstrating ability to perform activities of daily living does not relate to the nursing diagnosis of risk for injury. TEST-TAKING HINT: The test taker must be able to match the stated nursing diagnosis with the appropriate outcome. Outcomes need to be client-specific, realistic, attainable, and measura- ble, and contain a timeframe.

2. An amnestic disorder can result from the use of which of the following substances? Select all that apply. 1. Toxins. 2. Medications. 3. Aspartame. 4. Sedatives. 5. Alcohol.

✅1. Toxins, such as lead, mercury, carbon monoxide, organophosphates, and industrial solvents, are associated with, and contribute to, substance-induced persist- ing amnestic disorder. ✅2. Medications, such as anticonvulsants and methotrexate, are associated with, and contribute to, substance-induced persist- ing amnestic disorder. 3. Aspartame is an artificial, low-calorie sweetener. It is not associated with substance- induced persisting amnestic disorder. ✅4. Sedatives such as hypnotics and anxiolytics are associated with, and contribute to, substance-induced persisting amnestic disorder. ✅5. Alcohol, including whiskey, wine, beer, or other fermented or distilled liquors, is asso- ciated with, and contributes to, substance- induced persisting amnestic disorder. TEST-TAKING HINT: To answer this question cor- rectly, the test taker must understand the effects various substances may have on a client's cognition.

10. The nurse suspects a client is experiencing delirium. Which specific assessment information would support this suspicion? 1. A decreased level of consciousness with intermittent hypervigilance. 2. Slow onset of confusion and agitation. 3. Onset is insidious and relentless. 4. The symptoms last for 1 month or longer.

✅1.Delirium is characterized by a disturbance of consciousness and a state of awareness that may range from hypervigilance to stupor or semicoma. 2. The onset of delirium usually is quite abrupt, not slow, and often results in confusion, dis- orientation, restlessness, hyperactivity, and agitation. 3. The onset of dementia, not delirium, is insid- ious and relentless. The duration of delirium is usually brief. The symptoms of dementia, not delirium, last for 1 month or longer, often continuing and progressing throughout the lifetime. 4. The symptoms of delirium are usually short-term, lasting 1 week and rarely more than 1 month. The age of the client and the duration of the delirium influence the rate of symptom resolution. TEST-TAKING HINT: To answer this question, the test taker must be able to differentiate the assessment data associated with dementia and delirium.

22. A nursing student is studying delirium. Which of the following student statements indicates that learning has occurred? Select all that apply. 1. "The symptoms of delirium develop over a short time." 2. "Delirium permanently affects the ability to learn new information." 3. "Symptoms of delirium include the development of aphasia, apraxia, and agnosia." 4. "Delirium is a disturbance of consciousness." 5. "Delirium is always secondary to another condition."

✅1.Delirium is characterized by symptoms developing rapidly over a short time. 2. Delirium affects the ability to learn new information; however, this condition is tem- porary, not permanent. Because a client diag- nosed with delirium is extremely distractible and must be reminded repeatedly to focus, the ability to learn is impaired. 3. Aphasia, apraxia, and agnosia are cognitive deficits listed in the DSM-IV-TR as symp- toms of dementia, not delirium. ✅4. Delirium is characterized by a disturbance of consciousness and a change in cogni- tion. Reasoning ability and goal-directed behaviors are temporarily impaired. ✅5. Delirium is always secondary to another condition, such as a general medical condition, substance-induced delirium, substance-intoxication delirium, substance- withdrawal delirium, or simply a delirium due to multiple etiologies. TEST-TAKING HINT: To answer this question, the test taker must understand and recognize the DSM-IV-TR criteria for delirium. Because of the temporary nature of delirium, noting the word "permanently" assists the test taker to eliminate "2" immediately.

11. Studies have indicated that drastically reduced levels of acetylcholine are available in the brains of individuals diagnosed with Alzheimer's disease. Which cognitive deficit is primarily associated with this reduction? 1. Loss of memory. 2. Loss of purposeful movement. 3. Loss of sensory ability to recognize objects. 4. Loss of language ability.

✅1.The enzyme acetyltransferase is needed to synthesize the neurotransmitter acetylcholine. Some theorists propose that the primary memory loss that occurs in Alzheimer's disease is the direct result of reduction in acetylcholine available to the brain. 2. Loss of purposeful movement despite intact motor function (ataxia) may be associated with a decrease in acetylcholine; however, the development of ataxia is not the primary result of this reduction. Dopamine, norepi- nephrine, serotonin, and other substances may play a role in this condition. Also, loss of purposeful movement is a psychomotor, not cognitive, deficit. 3. Loss of sensory ability to recognize familiar objects audibly, visually, or tactically (agnosia) may be associated with a decrease in acetyl- choline; however, the development of agnosia is not a primary result of this reduction. Dopamine, norepinephrine, serotonin, and other substances also may play a role in this condition. 4. Loss of language ability (aphasia) may be associated with a decrease in acetylcholine; however, the development of aphasia is not a primary result of this reduction. Dopamine, norepinephrine, serotonin, and other sub- stances also may play a role in this condition TEST-TAKING HINT: When reading the question, the test taker needs to note the keyword "prima- rily." Various cognitive deficits may be associated with reduced levels of acetylcholine in the brain, but only "1" is primarily associated with this reduction.

14. The nursing supervisor in an extended care facility is managing the environment to best help the clients with dementia. Which should the nurse include in planning the living environment? A) Plan for the same caregivers to provide care to individuals as much as possible. B) Open the windows and doors to allow fresh air to circulate through the environment. C) Provide a buffet-style menu with many food choices. D) Assign peer-led exercise activates on a daily basis.

✅Ans: A Feedback: A structured environment and established routines can reassure clients with dementia. Familiar surroundings and routines help to eliminate some confusion and frustration from memory loss. Providing the same caregiver establishes familiarity and routine. Safety considerations involve protecting against injury, meeting physiologic needs, and managing risks posed by the environment. Open doors pose a safety risk of wandering away. Buffet-style meals require the client to make too many choices, thus adding to frustration. The nurse encourages clients to engage in physical activity because they may not initiate such activities independently; many clients tend to become sedentary as cognitive abilities diminish. Clients often are quite willing to participate in physical activities but cannot initiate, plan, or carry out those activities without assistance.

5. A client with dementia is unable to recognize ordinary objects, such as a pen or notebook. Which would this be a symptom of? A) Agnosia B) Amnesia C) Apraxia D) Aphasia

✅Ans: A Feedback: Agnosia is the inability to recognize familiar objects. Amnesia is failure to remember past events. Apraxia is impairment in the ability to execute motor functions despite intact motor abilities. Aphasia is a deterioration of language function.

3. Which is believed to be a risk factor specific to the development of delirium? A) Increased severity of physical illness B) Older age C) Baseline cognitive impairment D) Gradual decline in functioning

✅Ans: A Feedback: An estimated 10% to 15% of people in the hospital for general medical conditions are delirious at any given time. Onset is sudden. Delirium is common in older, acutely ill clients. Risk factors for delirium include increased severity of physical illness, older age, and baseline cognitive impairment such as that seen in dementia. Children may be more susceptible to delirium, especially that related to a febrile illness or certain medications such as anticholinergics. Delirium usually develops over a short period, sometimes a matter of hours, and fluctuates, or changes, throughout the course of a day. Prevalence of dementia also rises with age, and progression is gradual.

28. The caregiver of a client with Alzheimer's disease reports to the nurse that often the client will suddenly become angry during meals and nothing seems to calm him down. The nurse teaches the caregiver to use distraction techniques. Which response would be best to teach as an example of this technique? A) Let's look at what is on television. B) If you stop yelling, I will get your dessert. C) Don't you want to finish your meal? D) ìI don't understand what you are saying.

✅Ans: A Feedback: Distraction involves shifting the client's attention and energy to a more neutral topic. For example, the client may display a catastrophic reaction to the current situation, such as jumping up from dinner and saying, ìMy food tastes like poison!î The nurse might intervene with distraction by saying, ìCan you come to the kitchen with me and find something you'd like to eat?î or ìYou can leave that food. Can you come and help me find a good program on television?î (redirection/distraction). Influencing behavior with a reward is a behavioral technique. Asking a direct question is ineffective. Clarification is used to try to determine meaning behind the client's message.

4. Which patient is most likely suffering from dementia? A) A 90-year-old male who has experienced progressive mental decline that started with forgetfulness B) An 80-year-old female who has been in excellent health until she was admitted through the emergency department with a severe urinary tract infection and is now very anxious and is threatening staff C) A 6-year-old child who has just been administered conscious sedation for a closed reduction of a fractured wrist and says that her parents have three sets of eyes D) A 22-year-old male who was involved in a motorcycle crash without wearing a helmet now unable to remember where he is

✅Ans: A Feedback: Memory impairment is the prominent early sign of dementia. The course of dementia is usually progressive. A 90-year-old gentleman who has experienced progressive mental decline that started with forgetfulness is most likely suffering from dementia. An 80- year-old lady who has been in excellent health until she was admitted through the emergency department with a severe urinary tract infection is likely experiencing delirium. Delirium almost always results from an identifiable physiologic, metabolic, or cerebral disturbance or from drug intoxication or withdrawal. The 6-year-old who has just been administered conscious sedation is likely delirious. A 22-year-old male who was involved in a motorcycle crash without wearing a helmet and now cannot remember where he is likely experiencing an amnestic disorder.

16. The nurse caring for an elderly woman with dementia has asked the woman's children to bring old photo albums when they visit. Which best describes the usefulness of viewing photos when caring for the dementia client? A) Viewing photos is a form of reminiscence therapy for the client. B) Sharing photos will encourage interaction with other clients. C) This can help the children to correctly identify old photographs. D) Talking about the photos will encourage the client to live in the past.

✅Ans: A Feedback: Reminiscence therapy (thinking about or relating personally significant past experiences) is an effective intervention for clients with dementia. Rather than lamenting that the client is ìliving in the past,î this therapy encourages family and caregivers also to reminisce with the client. Reminiscing uses the client's remote memory, which is not affected as severely or quickly as recent or immediate memory. Photo albums may be useful in stimulating remote memory, and they provide a focus on the client's past.

13. A client with dementia is starting pharmacotherapy to slow the progression of cognitive decline. The client has a history of moderate but steady alcohol use over the past 45 years. Which medication should the nurse question as least suitable for this client? A) Tacrine (Cognex) B) Memantine (Namenda) C) Donepezil (Aricept) D) Rivastigmine (Exelon)

✅Ans: A Feedback: Tacrine (Cognex) is a cholinesterase inhibitor; however, it elevates liver enzymes in about 50% of clients using it. Lab tests to assess liver function are necessary every 1 to 2 weeks; therefore, tacrine is rarely prescribed. Memantine (Namenda) is an NMDA receptor antagonist that can slow the progression of Alzheimer's in the moderate or severe stages. Donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl) are cholinesterase inhibitors and have shown modest therapeutic effects and temporarily slow the progress of dementia.

7. The nurse is caring for a client with cognitive impairment. To determine whether the client is suffering from delirium or dementia, the nurse reviews the symptoms and course of each disorder. Place the letter A beside terms describing delirium and the letter B beside terms describing dementia. ____ Rapid onset ____ Progressive decline ____ Long-term memory impairment ____ Slurred speech ____ Hallucinations

✅Ans: A, B, B, A, A Feedback: Onset of delirium is rapid, but of dementia is gradual. Duration of delirium is brief, but of dementia is progressing. Delirium affects only short-term memory. Dementia begins with short-term memory loss and progresses to long-term memory loss. Slurred speech is characteristic of delirium. Speech with dementia is unchanged until the client begins to develop aphasia. Visual and tactile hallucinations are common with delirium, but rarely experienced with dementia.

11. The nurse is performing a health history with a client exhibiting signs of delirium. The nurse asks the client and family members about possible causes of the delirious state. Which would the nurse likely attribute as underlying causes for the client's delirium? Select all that apply. A) Recent alcohol use B) Dehydration C) Use of antihistamines D) Sleep disturbances E) Use of megadoses of vitamins F) Exposure to paint or gasoline

✅Ans: A, B, C, D, F Feedback: Because the causes of delirium are often related to medical illness, alcohol, or other drugs, the nurse obtains a thorough history of these areas. The nurse may need to obtain information from family members if a client's ability to provide accurate data is impaired. Information about drugs should include prescribed medications, alcohol, illicit drugs, and over-the-counter medications. Physiologic or metabolic causes include hypoxemia, electrolyte disturbances, renal or hepatic failure, hypoglycemia or hyperglycemia, dehydration, sleep deprivation, thyroid or glucocorticoid disturbances, thiamine or vitamin B12 deficiency, vitamin C, niacin, or protein deficiency, cardiovascular shock, brain tumor, head injury, and exposure to gasoline, paint solvents, insecticides, and related substances. Infectious processes include sepsis, urinary tract infection, pneumonia, meningitis, encephalitis, HIV, and syphilis.

32. Which are possible sources of frustrations for nurses caring for persons with dementia? Select all that apply. A) The clients do not retain explanations or instructions, so the nurse must repeat the same things continually. B) The nurse may get little or no positive response or feedback from clients with dementia. C) It can be difficult to remain positive and supportive to clients and family because the outcome is so bleak. D) It can be helpful for the nurse to talk to colleagues or even a counselor about personal feelings of depression and grief as the dementia progresses. E) The clients may seem not to hear or respond to anything the nurse does.

✅Ans: A, B, C, E Feedback: Working with and caring for clients with dementia can be exhausting and frustrating for both the nurse and caregiver. Teaching is a fundamental role for nurses, but teaching clients who have dementia can be especially challenging and frustrating. These clients do not retain explanations or instructions, so the nurse must repeat the same things continuously. The nurse may begin to feel that repeating instructions or explanations does not good because clients do not understand or remember them. The nurse may get little or no positive response or feedback from clients with dementia. It can be difficult to deal with feelings about caring for people who will never get better and go home. As dementia progresses, clients may seem not to hear or respond to anything the nurse says or does. Remaining positive and supportive to clients and family can be difficult when the outcome is so bleak. The nurse may need to deal with personal feelings of depression and grief as the dementia progresses; he or she can do so by discussing the situation with colleagues or even a counselor, but this is an intervention instead of a source of frustration for the nurse.

19. Which is the most effective intervention for clients with delirium? A) Giving detailed explanations B) Managing environmental stimuli C) Promoting rest with PRN medications D) Providing activities for distraction

✅Ans: B Feedback: Clients with delirium become overstimulated easily; their ability to process environmental stimuli is impaired.

2. A nurse working in an assisted living facility is holding an in-service for the nursing assistants. The nurse reviews common behaviors associated with cognitive deterioration associated with dementia. Which would cause the nurse to know that the assistants correctly understood if it were expressed during a posttest? A) The clients should be able to ask us for items they need. B) The clients may not recognize their family when they come to visit. C) The clients who are ambulatory can still carry out activities of daily living independently. D) The clients should know when to come to the dining room for meals.

✅Ans: B Feedback: Dementia is a mental disorder that involves multiple cognitive deficits, primarily memory impairment, and at least one of the following cognitive disturbances: (1) aphasia, which is deterioration of language function; (2) apraxia, which is impaired ability to execute motor functions despite intact motor abilities; (3) agnosia, which is inability to recognize or name objects despite intact sensory abilities; and (4) disturbance in executive functioning, which is the ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior.

29. The adult son of a client with dementia asks the nurse how he should respond when his mother repeatedly says she has had a busy day at work. The mother has not worked in over 20 years. Which is the best guidance that the nurse could offer? A) Ask her to explain what she did at work today that kept her busy. B) Go along with her thought of it having been a busy day, but do not refer to her work. C) Reorient her that she is at home and did not go to work. D) Give her 5 to 10 minutes of rest, and she will have no memory of the incident.

✅Ans: B Feedback: Going along means providing emotional reassurance to clients without correcting their misperception or delusion. The nurse does not engage in delusional ideas or reinforce them, but he or she does not deny or confront their existence. For example, a client is fretful, repeatedly saying, ìI'm so worried about the children. I hope they're okayî and speaking as though his adult children were small and needed protection. The nurse could reassure the client by saying, ìThere's no need to worry; the children are just fineî (going along). Time away is an effective technique for aggression.

31. A new nurse has been working with clients with Alzheimer's disease for almost 6 months. During a staff meeting, the nurse expresses frustration because the same instructions have to be given to clients on a daily basis. The nurse states, ìI feel like all my work doesn't do them any good.î Which should the nurse's supervisor encourage the nurse to do? A) Cease giving instructions because the clients will not remember them anyway. B) Try to stay supportive and meet the clients' needs at the current moment. C) Seek counseling if personal feelings get in the way of client care. D) Consider transferring to a different client care specialty area.

✅Ans: B Feedback: Teaching is a fundamental role for nurses, but teaching clients who have dementia can be especially challenging and frustrating. These clients do not retain explanations or instructions, so the nurse must repeat the same things continually. The nurse must be careful not to lose patience and not to give up on these clients. Discussing these frustrations with others can help the nurse to avoid conveying negative feelings to clients and families or experiencing professional and personal burnout. The nurse must remain positive and supportive to clients and family.

6. Which client would have an increased risk for delirium? A) An elderly woman with abdominal pain B) A 3-year-old child with a temperature of 103.2∞F C) A middle-aged woman newly diagnosed with multiple sclerosis D) A young adult male with gastroenteritis and dehydration

✅Ans: B Feedback: Young children with high fever are at risk for delirium. The other choices would not be the most likely candidates for increased risk for delirium.

23. The nurse is developing interventions to promote socialization in a client with moderate dementia. Which would provide a safe and secure environment for the client? A) A card game with other clients B) An activity with the nurse C) Decorating a bulletin board with the group D) Morning stretch group with music

✅Ans: B Feedback: The client has to interact only with the nurse, who will behave in a predictable way and will focus on the client's needs, without undue or unexpected disruptions. Group activities do not provide a safe and secure environment like an activity done with the nurse does.

30. The grown daughter of a woman with Alzheimer's disease reports to the nurse that she is trying to keep her mother's condition from worsening by asking her questions whenever they are together. Which will be accomplished by this intervention? A) Decrease environmental misinterpretation B) Improve memory retention C) Increase frustration D) Slow the progress of the disease

✅Ans: C Feedback: Alzheimer's disease is progressive; clients do not learn new information, and they become frustrated when asked to perform tasks they are not capable of doing.

10. Which distinguishes delirium from dementia? A) Delirium has an acute onset and is progressive in course. B) Delirium has a gradual onset and can be resolved. C) Dementia has a gradual onset and is progressive in course. D) Dementia has an acute onset and can be resolved.

✅Ans: C Feedback: Delirium has a sudden onset, and the underlying cause is treatable; by contrast, dementia has a gradual onset and is progressive rather than treatable.

17. The nurse is encouraging a group of clients with dementia to join in upper body range of motion exercises using light dumbbells. Which technique will most likely result in the greatest amount of participation? A) Show an instructional video just prior to the activity. B) Describe the exercise immediately before performing it. C) Demonstrate the exercises while clients simultaneously perform them. D) Perform the same routine daily to avoid the need for repeated instruction.

✅Ans: C Feedback: The nurse encourages clients to engage in physical activity because they may not initiate such activities independently; many clients tend to become sedentary as cognitive abilities diminish. Clients often are quite willing to participate in physical activities but cannot initiate, plan, or carry out those activities without assistance.

8. The daughter of a woman with dementia asks the nurse if her mother will ever be able to live independently again. Which would be the most appropriate response by the nurse? A) ìYou sound like you aren't ready for her to be dependent on caregivers. B) ìHer confusion is a temporary complication of her physical illness and should subside when the illness gets better. C) ìSymptoms of dementia gradually get worse. Unfortunately she will not be independent again. D) ìWith early treatment, mild dementia can be reversed. It may be possible.

✅Ans: C Feedback: The prognosis for dementia involves progressive deterioration of physical and mental abilities until death. Typically, in the later stages, clients have minimal cognitive and motor function, are totally dependent on caregivers, and are unaware of their surroundings or people in the environment. They may be totally uncommunicative or make unintelligible sounds or attempts to verbalize. Delirium secondary to physical illness will subside with physical recovery.

21. The nurse is working with a client who has hallucinations and delusions. The client tells the nurse she cannot take a shower because she is waiting for her husband to take her home. Which response by the nurse is best in this situation? A) It would be best if you just took your shower now.î B) You seem anxious and upset. C) You have plenty of time to shower before it's time to go home. D) Why are you thinking you're going home?

✅Ans: C Feedback: This is an example of going along with, rather than correcting, the client's misperception so that she can get on with her daily activities and not focus on being upset about not going home. The other choices are not the best responses in this situation.

18. A client with dementia gets angry and begins to yell at the nurse during mealtime. The nurse leaves the client's side for 5 to 10 minutes and then returns. Which of the following best explains the nurse's behavior? A) The nurse was unsure of how to calm the client. B) The nurse was frustrated and needed to take a ìtime-out.î C) The nurse gave the client a chance to calm down before resuming the meal. D) The nurse stepped away to verify the safety of other clients.

✅Ans: C Feedback: Time away involves leaving clients for a short period and then returning to them to reengage in interaction. For example, the client may get angry and yell at the nurse for no discernible reason. The nurse can leave the client for about 5 or 10 minutes and then return without referring to the previous outburst. The client may have little or no memory of the incident and may be pleased to see the nurse on his or her return.

20. The nurse is assessing a client with early signs of dementia. What is the nurse trying to determine when the nurse asks the client what he ate for breakfast that morning? A) Orientation B) Food preferences C) Recent memory D) Remote memory

✅Ans: C Feedback: The initial sign of dementia is memory loss for recent events that exceeds normal forgetfulness. Asking what the client ate for breakfast is not determining orientation, food preferences, or remote memory.

26. A client with moderate Alzheimer's disease is living with her grown daughter. Which statement by the daughter would indicate the need for intervention by the nurse? A) ìIt's distressing when my mother forgets my name.î B) ìI wish my sister would come to visit more often.î C) ìMother won't let anyone else do anything for her.î D) ìTaking care of my mother is a big responsibility.î

✅Ans: C Feedback: When the caregiver feels as though no one else can provide care, the risk for role strain is markedly increased. The other choices do not require intervention by the nurse.

24. The daughter of a client with dementia has been the primary caregiver for 5 months. The daughter expresses to the nurse, ìAt times it is so overwhelming! I feel I do not have a life anymore!î Which is the most helpful response by the nurse? A) ìAre you saying you don't want to care for your mother anymore? B) I know it is really hard. It takes a lot of work and you are doing such a good job. C) Your mother really appreciates what you do for her. You are the best one to care for her. D) ìHere is the number of a caregivers' support group. How do you think you would feel talking with others in the same situation?

✅Ans: D Feedback: Caregivers need outlets for dealing with their own feelings. Support groups can help them to express frustration, sadness, anger, guilt, or ambivalence; all these feelings are common. Attending a support group regularly also means that caregivers have time with people who understand the many demands of caring for a family member with dementia. The client's physician can provide information about support groups, and the local chapter of the National Alzheimer's Disease Association is listed in the phone book. Area hospitals and public health agencies also can help caregivers to locate community resources. The nurse should understand that the caregiver is asking for help when expressing frustration. The nurse should not dismiss the caregiver's feelings or in any way induce additional guilt.

25. Which statement by the nurse would be most appropriate to the family member who is the primary caregiver to a client with dementia? A) ìMost people seek help when they really need it.î B) ìWhat is wrong with your family? Can't they see you need help? C) ìYou should be grateful that you still have your family member around. D) ìYes, it is important for you to spend some time relaxing and doing what you like to do. This will help you to be better prepared to manage the demands of the caregiver role.

✅Ans: D Feedback: Caregivers need support to maintain personal lives. They need to continue to socialize with friends and to engage in leisure activities or hobbies rather than focus solely on the client's care. Caregivers who are rested, are happy, and have met their own needs are better prepared to manage the rigorous demands of the caregiver role. Most caregivers need to be reminded to take care of themselves; this act is not selfish but really is in the client's best long-term interests. Many times caregivers will say they will seek help when they really need it. However, they must maintain their own well-being and not wait until they are exhausted before seeking relief. The primary caregiver may believe other family members should volunteer to help without being asked, but other family members may believe that the primary caregiver chose to take on the responsibility and do not feel obligated to help out regularly. It is important for the family to express their feelings and ideas and to participate in caregiving according to their own expectations. Many families need assistance to reach this type of compromise. Asking the caregiver what is wrong with his or her family and pointing out that the caregiver needs help are not helpful to the caregiver. It would be better for the nurse to encourage family members to share their feelings and to compromise for the best interests of the client. Telling the caregiver that he or she should be grateful will only increase the caregiver's sense of guilt, which is not productive.

1. During the change of shift report in the intensive care unit, the nurse learns that a client has developed signs of delirium over the past 8 hours. Which behavior documented in the nursing notes would be consistent with delirium? A) Unable to identify a water pitcher B) Unable to transfer to sitting position C) Difficulty with verbal expression D) Disoriented to person

✅Ans: D Feedback: Delirium usually develops over a short period, sometimes a matter of hours, and fluctuates, or changes, throughout the course of the day. Clients with delirium have difficulty paying attention, are easily distracted and disoriented, and may have sensory disturbances such as illusions, misinterpretations, or hallucinations. Dementia symptoms include aphasia (deterioration of language function), apraxia (impaired ability to execute motor functions despite intact motor abilities), and agnosia (inability to recognize or name objects despite intact sensory abilities).

27. A nurse is educating a group of elderly community members about cognitive disorders. Which would the nurse include as a measure most likely to prevent Alzheimer's disease and other dementias? A) Crafts B) Cooking C) Watching television D) Reading

✅Ans: D Feedback: People who regularly participate in brain-stimulating activities such as reading books and newspapers or doing crossword puzzles are less likely to develop Alzheimer's disease than those who do not. Engaging in leisure-time physical activity during midlife and having a large social network are associated with a decreased risk for Alzheimer's disease in later life.

22. The nurse is caring for a client with Alzheimer's disease. The nurse observes that the client's pacing and mumbling to himself increase at mealtime and shift change. Which intervention should the nurse implement first? A) Administer an antianxiety drug such as lorazepam (Ativan) at these times. B) Explain the unit routine and the reasons for increased activity to the client. C) Keep unit activity to a minimum. D) Move the client to a quieter area during these times.

✅Ans: D Feedback: The nurse must alter the environment because the client will not learn new coping skills for frustrating or overly stimulating situations. Administering an antianxiety agent or explaining the routine of the unit and reasons for increased activity to the client may be done but would not be the initial intervention. The unit activity does not need to be kept to a minimum.

12. A client voluntarily admitted to the inpatient psychiatric unit is currently experiencing mild delirium. The client approaches the nurse and states, ìI'm going to take walk outside. I'll be back in about 10 minutes.î Which is the most appropriate nursing action? A) Further assess the client's motives for wanting to walk. B) Give the client permission to go on a walk on the grounds. C) Tell the client the walk is not allowed and restrict him to the unit. D) Designate a staff member to accompany the client on the walk.

✅Ans: D Feedback: The nurse teaches clients to request assistance for activities such as getting out of bed or going to the bathroom. If clients cannot request assistance, they require close supervision to prevent them from attempting activities they cannot perform safely alone. The nurse responds promptly to calls from clients for assistance and checks clients at frequent intervals.

9. Which statement made by the nurse would be most appropriate to an 89-year-old patient who is confused but has no history of dementia and is hospitalized for an acute urinary tract infection? A) ìYou are likely to become progressively more confused now. B) ìThis should be just a temporary situation.î C) ìDon't worry about it; everyone is confused when they are in the hospital. D) ìI know things are upsetting and confusing right now, but your confusion should clear as you get better.

✅Ans: D Feedback: ìI know things are upsetting and confusing right now, but your confusion should clear as you get better,î would be validating and giving information and would provide realistic reassurance to the client who has delirium as this is often an acute and temporary situation in elderly people who are acutely ill and have other risk factors such as medications and illness and age. ìYou are likely to become progressively more confused now,î is inaccurate as the person likely has delirium, and this will be an acute and temporary situation. ìThis should be just a temporary situationî provides some reassurance but no validation. ìDon't worry about it; everyone is confused when they are in the hospitalî is inaccurate.

15. The nurse encourages the client with dementia to meet nutritional needs. Which is the best approach to assist in meeting adequate dietary intake? A) Sit with the client as long as necessary to complete the meal. B) Provide entertainment during meals such as television or music. C) Avoid between-meal snacks to encourage appetite. D) Serve meals in small, bite-size pieces.

✅Ans: D Feedback: Clients may eat poorly because of limited appetite or distraction at mealtimes. The nurse addresses this problem by providing foods clients like, sitting with clients at meals to provide cues to continue eating, having nutritious snacks available whenever clients are hungry, and minimizing noise and undue distraction at mealtimes. Clients who have difficulty manipulating utensils may be unable to cut meat or other foods into bite-sized pieces. The food should be cut up when it is prepared, not in front of clients, to deflect attention from their inability to do so. Food that can be eaten without utensils, or finger foods such as sandwiches and fresh fruits, may be best.