EAQ Ch. 18 Mental Health Nursing

Which newly hospitalized client does the nurse least need to monitor closely for development of delirium?

72-year-old who says, "I have one glass of wine every evening to stimulate my appetite."

In a workshop for dementia, the nurse provides information about the different types of services available for dementia clients. What appropriate community services does the nurse mention?

Adult day care

The health care provider mentions to the nurse that a client who is about to be admitted has sundown syndrome. What can the nurse expect to observe nightly?

Agitation

Which best describes the usual development of Alzheimer disease?

Progressive deterioration

The nurse is assessing a client suspected of having Alzheimer disease (AD). What action by the client does the nurse identify as a sign of agnosia?

Has difficulty identifying familiar sounds like the ring of the telephone

What is the most helpful nursing intervention to orient a client experiencing confusion associated with a neurocognitive disorder?

Offer a consistent daily routine and easy-to-read clocks.

The nurse assessing a non-English speaking client gently declines the sibling's offer to serve as the translator. What is the reason for the nurse to take this step?

The sibling may conceal some important information given by the client.

Which nursing intervention would be most appropriate for an older individual suspected of being at risk for the development of the unique symptoms of delirium?

Assessing orientation to person, place, and time every 2 hours.

The nurse is teaching the family caregivers how to communicate with a client who has dementia. What communication strategy can improve orientation of the client?

Call the person by name every time you see him or her.

A client diagnosed with delirium strikes out physically at a staff member. What is the most likely cause of this behavior?

State of fear

Which nursing interventions are appropriate for a client experiencing delirium? Select all that apply.

- Offer frequent brief, caring phrases to the client. - Acknowledge the client's feelings and emotions. - Keep the head of the client's bed elevated.

Which practice demonstrates a proactive approach to minimizing the stress commonly experienced by nursing staff caring for the cognitively impaired client? Select all that apply.

- Realistic client outcomes - Thorough understanding of the disorder - Reasonable expectations of client abilities

A nurse communicates with a diabetic client during a regular check-up. The nurse finds that the client is showing symptoms of Alzheimer disease. Which response by the client supports the nurse's diagnosis?

"I often meet Mr. Abraham Lincoln during my walk."

A client is brought to the hospital by an adult child, who visited this morning and found the client to be confused and disoriented. When the client is admitted, the adult child states, "I'll take my parent's glasses and hearing aid home so they don't get lost." What would be the most appropriate reply from the nurse?

"I would like to have your parent wear them. It will help alleviate confusion and disorientation."

An 84-year-old tells the nurse, "I do four or five number puzzles every day to keep my brain healthy and sharp." When considering a holistic approach to maintaining mental health, how should the nurse respond?

"Let's think of some other activities we can add to your daily routine."

A family member asks the nurse, "I know my uncle's Alzheimer disease has progressed, but is there any medication that can help him now?" Which response by the nurse is correct?

"There are a few medications that may help. Let's discuss it with health care provider."

A nurse directs the nursing assistant to offer fluids to a client who is being detoxified from alcohol. The nursing assistant responds, "That client doesn't deserve my help. Will power and faith could have avoided this situation." What is the nurse's best response?

"We accept alcoholism as a disease and provide compassionate care."

A nurse assists a client with moderate stage Alzheimer disease at mealtime. Which statement should the nurse use?

"Would you like beans or potatoes?"

A client with a history of chronic alcohol use is prescribed disulfiram to treat the addiction. Which information concerning the effect of this medication should the nurse provide the client?

"You can experience adverse effects if you consume alcohol while taking this medication."

As part of a clinical study, the nurse has to select elderly hospitalized clients for whom delirium is their most frequent complication. Based on what cardinal features does the nurse select the clients? Select all that apply.

- Acute onset and fluctuating course - Reduced ability to direct, focus, and sustain attention - Disorganized thinking - Disturbed consciousness

The nurse is caring for a geriatric client diagnosed with delirium. Which symptoms is the client likely to manifest? Select all that apply

- Altered consciousness - Sundown syndrome - Disorientation - Hallucinations

The nurse is caring for a geriatric client diagnosed with delirium. Which symptoms is the client likely to manifest? Select all that apply.

- Altered consciousness - Sundown syndrome - Disorientation - Hallucinations

Which question should be asked when considering the evaluation of outcomes for a client experiencing cognitive dysfunction? Select all that apply.

- Are the stated outcomes measureable? - Is the client capable of achieving the outcomes? - Are the client's cognitive skills deteriorating? - When were the client's outcomes last evaluated?

Which statements regarding the practice of culturally relevant mental health nursing are accurate? Select all that apply.

- Clients' needs are shaped by their individual cultures. - Culturally-relevant nursing care is fundamental to the promotion of well-being. - Culture includes beliefs, values, and practices. - The mental health of client is dependent on that client's individual culture.-

What initial assessments should the nurse implement in order to determine a proper plan of treatment and care for a client diagnosed with a substance abuse disorder? Select all that apply.

- Clinical examination of background - Pattern of substance use - Strengths and level of willingness to change - Assessment of comorbidites

The nurse is formulating a safe environment plan for the caregivers of a client diagnosed with Alzheimer disease. What does the nurse consider in the plan? Select all that apply.

- Gradually restricting driving - Labeling all rooms and drawers - Supervising smoking

A client is diagnosed with dementia. Which symptoms is the client likely to manifest? Select all that apply.

- Impaired judgment - No emotional expression

The nurse gives instructions to family members who provide home care for an 86-year-old client diagnosed with moderate stage Alzheimer disease. Which interventions are important and beneficial to teach the family? Select all that apply.

- Select clothing with easy fasteners to facilitate dressing. - Encourage the family to use support resources such as adult day care or respite care. - When the client becomes upset, listen briefly, provide support, and then change the topic.

A client on selective serotonin reuptake inhibitors has symptoms of delirium. What interventions are appropriate when caring for the client? Select all that apply.

- The nurse performs regular assessment of the client. - The nurse places a calendar and watch beside the client. - The nurse notes the sleeping time of the client.

A client is diagnosed with dementia. What nursing care considerations are appropriate for this client? Select all that apply.

- The nurse provides finger food to the client - The nurse places an identification bracelet on the client

A client diagnosed with Alzheimer disease has become more forgetful and has difficulty performing familiar tasks like bathing and dressing. The nurse would assess the client as being in which stage of Alzheimer disease?

Stage 3, moderate-severe

How does the counselor integrate motivational interviewing as a tool in the treatment plan of a client with a substance use disorder?

It help the counselor use strategies to resolve ambivalence and evoke internally motivated change.

The nurse is caring for a client with Alzheimer disease who tends to get frightened and cry out at night. What nursing intervention is most appropriate for this client?

Keep the area well lit at night

Which initial intervention is the nurse most likely to suggest to the family members of a client diagnosed with Alzheimer disease who is experiencing incontinence?

Label the bathroom door with a picture.

An elderly client, who had been healthy and living independently, was hospitalized with heart failure. The client was treated with diuretics and antihypertensive medications. On the third hospital day, the client became very irritable and said, "Little yellow bugs are crawling across my sheets." What is the most appropriate assessment of this scenario

The client is experiencing illusions secondary to delirium.

A client diagnosed with Alzheimer disease looks confused when the phone rings and cannot recall many common household objects by name. What term will the nurse use to document this loss of function?

Agnosia

A client diagnosed with Alzheimer disease picks up his or her glasses from the bedside table but does not recognize what they are or their purpose. The nurse will document this behavior using which term?

Agnosia

Which type of dementia has a clear genetic link?

Alzheimer's disease

The family caregivers of an elderly Alzheimer disease client are feeling overburdened and overwhelmed by the situation and wish to admit the client to an assisted care facility. What could be the primary reason?

Caregiver role strain

The nurse caring for a client with Alzheimer disease can anticipate that the family will need information about which kind of medication?

Cholinesterase inhibitors

The family members of a client with stage 2 Alzheimer disease have jobs and cannot provide adequate supervision for the client. What is a reasonable alternative for the nurse to explore with them?

Day Care

Which change in neurotransmitters occurs in Alzheimer disease?

Decreased acetylcholine

A family member reports that the client had been oriented and able to carry on a logical conversation last evening, but this morning is confused and disoriented. What condition does the nurse suspect?

Delirium

Dementia in an older adult is often a misdiagnosis for what condition?

Depression

A client with Alzheimer disease has mild memory loss and no symptoms of dementia. Which drug is included in the treatment plan of the client?

Galantamine

Which statement about Alzheimer disease (AD) is correct?

Hypertension, diminished activity, and head injury increase the risk of AD.

A 72-year-old client hospitalized with pneumonia and experiencing delirium points to the intravenous (IV) pole and screams, "Get him out of here! He's going to hurt me!" What term is used to describe the reaction the client is having?

Illusion

A client diagnosed with delirium insists that a vacuum hose is a large, poisonous snake. What term will the nurse use to describe what the client is demonstrating?

Illusion

What factor places a client of a culture different from that of the health care provider at highest risk for misdiagnosis of a psychiatric problem?

Insensitive interviewing techniques

What characteristic should the nurse monitor to best ensure the safety of a client who has a blood alcohol level of 0.08 mg %?

Motor coordination

A client with a history of drug abuse reports experiencing insomnia. Upon assessment the nurse finds that the client has enlarged pupils associated with continuous tearing of the eyes. In the report, the nurse documents that the client was showing signs of which related condition?

Opioid withdrawal

The term "perceptual disturbance" refers to difficulty accomplishing what task?

Processing information about one's internal and external environment

Three months after the death of his wife, an 86-year-old man begins having difficulty with concentration and sleep. Family members must provide reminders and encouragement for him to bathe, take prescribed medications, and eat regularly. Which nursing action is most appropriate?

Refer this client for further evaluation and treatment of suspected depression.

A client diagnosed with stage 2 Alzheimer disease begins a new prescription for rivastigmine. Which nursing diagnosis is the priority?

Risk for imbalanced nutrition, less than body requirements

A 75-year-old client is hospitalized with sudden onset confusion and disorientation. The client wanders and becomes agitated without any apparent stimulus. What is the highest priority nursing diagnosis?

Risk for injury.

A nurse is caring for a client with dementia. What client behavior is typical of dementia?

The client demands the attention of the nurse

The nurse is assessing a client with dementia. What problem does the nurse document as related to apathy?

The client engages in little conversation.

A client was in an automobile accident, and although there is the odor of alcohol on the client's breath, the client's speech is clear, and the client is alert and can answer questions. The client's blood alcohol level is determined to be 0.30 mg %. What conclusion can be drawn?

The client has a high tolerance to alcohol.

A client with Parkinson disease reports that bugs are crawling on his bed. The nurse checks the bed and finds peanuts on the bed. What does the nurse conclude from the client's behavior?

The client has impaired environmental interpretation syndrome.

An elderly client is hospitalized with pneumonia and treated with multiple antibiotics. After 2 days, the client becomes irritable and restless, and says to the nurse, "My pet parakeet flew across the room." A family member says the client has been healthy and living independently but does not own a pet. What is the most likely analysis of this scenario?

The client is experiencing illusions secondary to delirium

An elderly postoperative client at a well-maintained health care facility is terrified and reports seeing "giant spiders crawling over the bedclothes." Which is the most appropriate analysis of the situation?

The client is visually hallucinating due to delirium.

A client with Alzheimer disease tends to wander at night. What appropriate measures does the nurse follow to ensure client safety?

The nurse makes the client wear a bright vest.

A nurse explains the methods of improving self-care in the client with dementia to one of the client's family members. What action from the family member most indicates effective grasp of the teaching and the ability to help the client be more self-sufficient?

Use name tags on the clients clothes for easy recognition

While interacting with a client diagnosed with a progressive neurocognitive disorder, the nurse observes that the client has slow responses and difficulty finding the right words. What is the nurse's best initial action?

Use silence to allow the client an opportunity to compose responses.