EXAM 3 Psych Prep-U 24
aphasia
is a deterioration of language function.
Blood flow in the vessels to the brain are blocked.
A client has vascular neurocognitive disorder. When teaching the family about the cause of this disorder, which would the nurse expect to integrate into the explanation?
take a nap mid afternoon and before dinner
Which client behavior should the nurse attempt to change when managing a client's tendency to wander and pace at night?
Risk for injury related to confusion and cognitive deficits
Which nursing diagnosis would be the priority for the client experiencing acute delirium?
Apraxia
Which term is used to describe the inability to execute motor functioning, despite intact motor abilities?
Achievement of self-esteem needs
Which would not be considered a primary goal of nursing care for a client with delirium?
Executive functioning
is the ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior.
agnosia
is the inability to recognize the name of objects.
identify a picture of a car.
"You're in the hospital. You did not drink for several days, but you're getting better now."
Slow deterioration of memory and function
A client is diagnosed with dementia related to Parkinson's disease. While at a clinic visit, a cholinesterase inhibitor is prescribed for the client. The nurse knows that this type of medication would be prescribed for the client to achieve which goal?
Providing emotional support and gentle reminders
A client is in the mild stage of dementia due to Alzheimer's disease. Which intervention would be most appropriate?
Intellectual ability, health history, and self-care ability
A client was admitted to an inpatient unit with a diagnosis of dementia. A nursing assessment and interview of the client would include what?
Which is a metabolic cause of delirium?
Hypoglycemia
Use of disposable, adult diapers
To manage voiding issues, such as incontinence, male clients diagnosed with dementia would best be managed by what?
An altered level of consciousness
What is the primary sign of delirium?
The geriatrician has prescribed an 80-year-old female client donepezil (Aricept) in order to treat her dementia, Alzheimer's type. Which of the following teaching points should the nurse provide to the client's husband about her new medication?
"Aricept won't cure your wife's dementia of Alzheimer's type, but it has the potential to slow down the progression of the disease." Cholinesterase inhibitors such as donepezil (Aricept) cannot cure DAT, but they can slow the progression of the disease and can stabilize symptoms. The drug does not directly affect sleep patterns. (less)
Remove hazards from the environment.
A client with Alzheimer's disease has a nursing diagnosis of risk for injury related to memory loss, wandering, and disorientation. Which nursing intervention should appear in this client's care plan to prevent injury?
"You're in the hospital. You did not drink for several days, but you're getting better now."
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?
The nurse understands that numerous comorbidities can contribute to the development of dementia. Which client may be at risk for dementia?
A 49-year-old client whose human immunodeficiency virus (HIV) has progressed to acquired immunodeficiency syndrome (AIDS)
The nurse understands that numerous comorbidities can contribute to the development of dementia. Which of the following clients may be at risk for dementia?
A 49-year-old man whose HIV has progressed to AIDS
N-methyl-D-aspartate (NMDA) receptor antagonist
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?
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. The nurse recognizes that this activity is likely to do which of the following? Decrease environmental misinterpretation Improve memory retention Increase frustration Slow the progress of the disease
Increase frustration
Which is the most effective intervention for clients with delirium? Giving detailed explanations Managing environmental stimuli Promoting rest with PRN medications Providing activities for distraction
Managing environmental stimuli
In clients with Alzheimer's disease, neurotransmission is reduced, neurons are lost, and the hippocampal neurons degenerate. Which neurotransmitter is most involved in cognitive functioning?
Acetylcholine
In clients with Alzheimer's disease, neurotransmission is reduced, neurons are lost, and the hippocampal neurons degenerate. Which neurotransmitter is most involved in cognitive functioning? Acetylcholine Epinephrine Serotonin Norepinephrine
Acetylcholine
After teaching a group of nursing students about dementia, the instructor determines a need for additional teaching when the students identify which as a primary goal of nursing care?
Achievement of self-esteem needs
Which of the following would not be considered a primary goal of nursing care for a client with delirium?
Achievement of self-esteem needs
A client with dementia is unable to recognize ordinary objects, such as a pen or notebook. The nurse recognizes this symptom as ...
Agnosia
A client diagnosed with Alzheimer's disease has an alteration in language ability. This alteration would be documented as what?
Aphasia
An 82-year-old client with a diagnosis of vascular dementia has been admitted to the geriatric psychiatry unit of the hospital. In planning the care of this client, which outcome should the nurse prioritize?
The client will remain free from injury.
A client with amnestic disorder is being evaluated for dementia. Which of the following is a diagnostic characteristic of amnestic disorder?
History and physical examination indicative of memory impairment Diagnostic characteristics of amnestic disorder include memory impairment not solely limited to periods of delirium, history and physical examination indicative of medical condition underlying the memory impairment, demonstration of significant problems with social or occupational functioning, and memory significantly decreased from usual level. (less)
Which of the following is a metabolic cause of delirium?
Hypoglycemia Hypoglycemia is a metabolic cause of delirium. Meningitis and encephalitis are infection-related causes. Alcohol intoxication is a drug related cause of delirium.
Delirium can be differentiated from many other cognitive disorders in which way?
It has a rapid onset and is highly treatable if diagnosed quickly.
Jean has early Alzheimer's disease. When asked about her family history, she relates that she has two children who are both grown and who visit her around the holidays each year. The nurse subsequently discovers that Jean has one child who is currently assigned overseas and has not been home for 2 years. Which of the following would best describe Jean's behavior?
Jean is confabulating, most likely to cover for her memory deficit. Jean may have some difficulty recalling events or knowledge that she formerly knew to be fact. Because of the inability to recall recent events, she may be confabulating, or filling in memory gaps with fabricated or imagined data. (less)
A client with dementia is having difficulty clearly communicating about physical needs. When teaching the caregiver about ways to assist the client in meeting physical needs, which instruction would the nurse most likely include?
Keep a record of bowel movements.
While reviewing the medical record of a client with moderate dementia of Alzheimer type, a nurse notes that the client has been receiving memantine. The nurse identifies this drug as which type?
NMDA receptor antagonist
A older adult client develops delirium secondary to an infection. Which would be the most likely cause?
Pneumonia
A older adult client develops delirium secondary to an infection. Which would be the most likely cause? Pneumonia Cellulitis Low platelet count Appendicitis
Pneumonia
Which is an infection-related cause of delirium?
Pneumonia
Which of the following is an infection-related cause of delirium?
Pneumonia
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, opening containers for the client.
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.
When planning care for a client newly diagnosed with Alzheimer's disease, the nurse should focus on ...
Providing a safe, structured environment
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?
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?
Reminding the client multiple times that he or she will be soon having a bath
A client with Alzheimer's disease has a nursing diagnosis of risk for injury related to memory loss, wandering, and disorientation. Which nursing intervention should appear in this clients care plan to prevent injury?
Remove hazards from the environment
Which of the following nursing diagnoses would be the priority for the client experiencing acute delirium?
Risk for Injury related to confusion and cognitive deficits The plan of care must be deliberately designed to meet the client's unique needs, with safety always being the nurse's highest priority. Risk for injury is a NANDA diagnosis and the etiology of confusion and cognitive deficits are factors that can be modified through nursing care. (less)
Which nursing diagnosis would be the priority for the client experiencing acute delirium?
Risk for injury related to confusion and cognitive deficits
Which can be identified as a hallmark symptom of dementia?
Short-term memory loss
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?
Signs of stress
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.
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 removes the client's surgical bandage and begins picking at the sheets.
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.
Major goals for the nursing care of clients with dementia should include which of the following?
The client will be safe; be physiologically stable; have infrequent episodes of agitation. Safety is always the nurse's first priority; patients with dementia often cannot meet their basic physical needs; and agitation is a common emotional response to confusion and disorientation. (less)
A nurse is caring for a client with delirium. The nurse assesses the client's activities of daily living (ADLs) on a daily basis. What is the most likely reason for assessing these so frequently? Choose the best answer.
To assess for fluctuation in the client's capabilities Clients with organic diseases like delirium tend to have fluctuations in their ability to carry out activities of daily living. Thus, the nurse should assess these daily. Although the nurse should encourage the client to make decisions about treatment amd assist the client in establishing a daily routine, these actions do not require daily assessment. Assess the prognosis of the client after therapy also is not required daily. (less)
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?
Yes, because of the head injury and medication
The nurse documents that a client diagnosed with dementia of the Alzheimer's type is exhibiting agnosia when the client is observed being unable to ... identify a picture of a car. button a blouse. find words to describe the client's daughter's appearance. open juice and insert a straw into the container.
identify a picture of a car.
Apraxia is
the impaired ability to execute motor functions despite intact motor abilities.
The geriatrician has prescribed an 80-year-old client donepezil in order to treat the client's dementia, Alzheimer's type. Which teaching points should the nurse provide to the client's spouse about the new medication?
"Donepezil won't cure your spouse's dementia of Alzheimer's type, but it has the potential to slow down the progression of the disease."
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?"
The nurse is assessing a client who has received a tentative diagnosis of delirium. The nurse is explaining to the family about the major cause of the client's condition. Which statement by the nurse would be most appropriate?
"His diagnosis is primarily based on the rapid onset of his change in consciousness." The key diagnostic indicator for delirium is impaired consciousness, which is usually sudden in onset. Although infection may be an underlying cause, and other cognitive changes may occur such as problems with memory, orientation, and language, impaired consciousness developing over a short period is key. (less)
A 73-year-old client has been brought to the emergency department by the client's adult children due to abrupt and uncharacteristic changes in behavior, including impairments of memory and judgment. The subsequent history and diagnostic testing have resulted in a diagnosis of delirium. Which teaching point about the client's diagnosis should the nurse provide to the family?
"If the underlying cause of delirium is identified and treated, most people return to their previous level of functioning."
An 80-year-old client with Alzheimer's disease is prescribed donepezil. Which teaching points should the nurse provide to the client's spouse about the new medication?
"The drug won't cure the client's Alzheimer's, but it has the potential to slow down the progression of the disease."
A client diagnosed with Alzheimer's disease says, "I'm so afraid. Where am I? Where is my family?" How should the nurse respond?
"You are in the hospital and you are safe here. Your family will return at 10 o'clock, which is in 1 hour from now"
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?
"You're in the hospital. You did not drink for several days, but you're getting better now."
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."
A nurse is providing care to a client with dementia who is hyperactive. A diet high in which of the following would be most appropriate to include in the nutritional plan for this client? ~select all that apply~
- Carbohydrates - Protein
A client demonstrates an understanding about the risk factors for developing dementia when engaging in which health promotion activities? ~select all that apply~
- Eating a diet that provides sufficient amounts of B vitamins - Regularly reads fictional novels for entertainment - Does the daily newspaper crossword puzzle - Exercises at the gym 3 times a week
The nurse is caring for a client with delirium. Which interventions may help manage this client? ~select all that apply~
- Speak in simple sentences - Provide orienting verbal cues when talking with the client - Allow adequate time for the client to comprehend and respond
A nurse is giving instructions to a client diagnosed with delirium. What might the nurse repeat the instructions frequently? ~select all that apply~
- The client may have impaired attention - The client may have impaired recent and immediate memory
A nurse is working with a client, and family of the client, who has a diagnosis of Alzheimer's disease. The nurse explains to the client and family that the average course of the disease is how many years? 10 15 20 25
10
The nurse wants to prevent increasing the client's confusion.
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?
Which would not be considered a primary goal of nursing care for a client with delirium?
Achievement of self-esteem needs
A nurse is working with a client, and family of the client, who has a diagnosis of Alzheimer's disease. The nurse explains to the client and family that the average course of the disease is how many years?
10 Alzheimer's disease is a progressive brain disorder that has a gradual onset but causes an increasing decline in functioning, including loss of speech, loss of motor function, and profound personality and behavioral changes such as paranoia, delusions, hallucinations, inattention to hygiene, and belligerence. It is evidenced by atrophy of cerebral neurons, senile plaque deposits, and enlargement of the third and fourth ventricles of the brain. Risk for Alzheimer's disease increases with age, and average duration from onset of symptoms to death is 8 to 10 years. (less)
The client removes the client's surgical bandage and begins picking at the sheets.
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?
Reminding the client multiple times that he or she will be soon having a bath
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?
Personality change, wandering, and inability to perform purposeful movements
A client has experienced a gradual flattening of affect, confusion, and withdrawal and has been diagnosed with Alzheimer's disease. Which additional findings would the nurse most likely assess?
Monitor amount of environmental stimulation and adjust as needed.
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?
History and physical examination indicative of memory impairment
A client with amnestic disorder is being evaluated for dementia. Which is a diagnostic characteristic of amnestic disorder?
Physical restraints may increase the client's agitation.
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?
Keep a record of bowel movements.
A client with dementia is having difficulty clearly communicating about physical needs. When teaching the caregiver about ways to assist the client in meeting physical needs, which instruction would the nurse most likely include?
Oxidative stress
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?
"Has your parent taken any medications recently?"
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?
To assess for fluctuation in the client's capabilities
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?
GI symptoms
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
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?
A client is diagnosed with Alzheimer's disease. While assessing the client, the nurse notes that the client has trouble identifying objects such as a key and spoon. The nurse would document this as what?
Agnosia
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?
Agnosia
Which of the following terms describes an inability to recognize or name objects despite intact sensory abilities?
Agnosia
Which of the following terms describes an inability to recognize or name objects despite intact sensory abilities? Apraxia Aphasia Agnosia Executive functioning disturbance
Agnosia
A client is diagnosed with Alzheimer's disease. While assessing the client, the nurse notes that the client has trouble identifying objects such as a key and spoon. The nurse would document this as which of the following?
Agnosia Deficits typically assessed in clients with Alzheimer's disease include: aphasia (alterations in language ability), apraxia (impaired ability to execute motor activities despite intact motor functioning), agnosia (failure to recognize or identify objects despite intact sensory function), or a disturbance of executive functioning (ability to think abstractly, plan, initiate, sequence, monitor, and stop complex behavior). (less)
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?
Alzheimer's disease
A client with dementia is having difficulty finding the words that the client wants to use. When the client could not remember the name of the client's shoes, he referred to them as, "the things you put on your feet." What is the name for this condition?
Aphasia
Delirium related to underlying medical problem
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?
A client has been newly diagnosed with delirium. The nurse knows that the primary sign of delirium includes which of the following?
An altered level of consciousness
What is the primary sign of delirium?
An altered level of consciousness The primary sign of delirium is an altered level of consciousness that is seldom stable and usually fluctuates throughout the day. All other options are not the primary sign of delirium. (less)
Yes, because of the head injury and medication
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?
The client has difficulty finding words
An older client comes to the clinic for a yearly physical exam. During the assessment, the client tells the nurse that the client sometimes has begun feeling anxious about the client's forgetfulness. The nurse notes the client may have mild dementia. Which finding would lead the nurse to conclude this?
A client with dementia is having difficulty finding the words that he wants to use. When he could not remember the name of his shoes, he referred to them as, "the things you put on your feet." What is the name for this condition?
Aphasia
A client diagnosed with Alzheimer's disease has an alteration in language ability. This alteration would be documented as which of the following?
Aphasia Aphasia is an alteration in language ability. Agnosia is the failure to recognize or identify objects despite intact sensory function. Apraxia is impairment in the ability to execute motor activities despite intact motor functioning. Akinesia is impaired muscle movement that may occur in Parkinson's disease. (less)
A client has been diagnosed with dementia and is exhibiting several cognitive disturbances. Which of the following terms is used to describe the inability to execute motor functioning despite intact motor abilities? Apraxia Aphasia Agnosia Executive functioning
Apraxia
Which of the following terms is used to describe the inability to execute motor functioning, despite intact motor abilities?
Apraxia
Which term is used to describe the inability to execute motor functioning, despite intact motor abilities?
Apraxia
When conducting a nursing assessment of a client experiencing moderate cognitive dysfunction, the nurse can best prepare for an effective interview by ensuring what?
Asking a family member to be present during the assessment
A nurse is reviewing a journal article about Huntington's disease and the role of genetics. The nurse demonstrates understanding of the information by identifying which type of genetic transmission as being seen in this condition? Autosomal dominant Autosomal recessive X-linked recessive X-linked dominant
Autosomal dominant
When giving tacrine (Cognex) to an elderly client, the nurse must be aware of what information?
Because the liver is most vulnerable to tacrine, liver function tests must be done periodically
When giving tacrine to an elderly client, the nurse must be aware of what information?
Because the liver is most vulnerable to tacrine, liver function tests must be done periodically.
A client has vascular neurocognitive disorder. When teaching the family about the cause of this disorder, which would the nurse expect to integrate into the explanation?
Blood flow in the vessels to the brain are blocked.
A client has vascular neurocognitive disorder. When teaching the family about the cause of this disorder, which would the nurse expect to integrate into the explanation? Strands of protein are tangled together. Blood flow in the vessels to the brain are blocked. Fragments mix with molecules to make plaques in the brain. Acetylcholine production is decreased.
Blood flow in the vessels to the brain are blocked.
A nurse makes a home visit to a family caring for a client with Alzheimer's disease. The client's wife tells the nurse that she hasn't been out of the house for more than 2 weeks because her sister has been unable to help care for the client. Which nursing diagnosis would the nurse identify as the priority?
Caregiver Role Strain related to social isolation Although family coping, activity intolerance, and powerlessness may be issues, the priority nursing diagnosis is Caregiver Role Strain related to social isolation, as evidenced by the wife's statement of not being out of the house for 2 weeks. The nurse should assist the client's wife in obtaining respite care if it is available. (less)
Impaired attention, memory, and abstract thinking
Cognitive disorders are characterized by what?
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?
Delirium related to underlying medical problem
An 80-year-old is brought to the clinic by his wife. He has a history of peripheral vascular disease and Type 2 diabetes. The wife states that he hasn't seemed himself for the preceding few days, noting that he has been lethargic and mildly confused at times and has been incontinent of urine. She reports that his blood glucose levels have been elevated. The nurse considers which of the following as the most likely explanation for the client's change in mental status?
Delirium related to underlying medical problem Any disturbance in any organ or system that affects the brain can disrupt metabolism and neurotransmission, leading to a decline in cognition and function. Infections, fluid and electrolyte imbalances, and drugs are the most frequent causes of delirium. Older adults are especially susceptible to delirium disorders because the aging neurologic system is particularly vulnerable to insults caused by underlying systemic conditions. Indeed, delirium often predicts or accompanies physical illness in older adults. (less)
The nurse can distinguish delirium from dementia by knowing which of the following?
Dementia has a gradual onset and is progressive in course.
A client voluntarily admitted to the inpatient psychiatric unit is currently experiencing mild delirium. The client is restless, approaches the nurse and states, "I'm going to take a walk outside. I'll be back in about 10 minutes." Which is the most appropriate nursing action? Further assess the client's motives for wanting to walk. Give the client permission to go on a walk on the grounds. Tell the client the walk is not allowed and restrict the client to the unit. Designate a staff member to accompany the client on the walk.
Designate a staff member to accompany the client on the walk.
The wife caregiver of a client with dementia tells the nurse that her husband has been agitated lately. She states, "I don't know how to handle this. He was always such a gentle person!" Which of the following interventions should the nurse suggest?
Distract the client with family photos and discuss the events pictured
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?
Distract the client with family photos and discuss the events pictured.
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.
Which type of therapy involves shifting the client's attention and energy to a more neutral topic? Going along Distraction Time away Reminiscence therapy
Distraction
A client with Alzheimer's disease is confused and mumbling incoherently and rambling. To help redirect the client's attention, the nurse should encourage the client to ...
Fold towels
A client with Alzheimer's disease is confused and mumbling incoherently and rambling. To help redirect the client's attention, the nurse should encourage the client to ... Fold towels Play chess with another client Put together a 250-piece puzzle Perform an aerobic exercise
Fold towels
Which of the following is the hallmark of beginning mild dementia?
Forgetfulness The hallmark of the initiation of mild dementia is forgetfulness. Memory impairment is the prominent early sign of dementia.
When describing the dementia associated with Huntington disease, a nurse understands that the problems involving behavior and attention arise from a disruption in which lobe of the brain? Frontal Occipital Parietal Temporal
Frontal
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
The adult child of a client with dementia asks the nurse how the adult child should respond when the client repeatedly says the client has had a busy day at work. The client has not worked in over 20 years. Which is the best guidance that the nurse could offer? Ask the client to explain what the client did at work today that kept the client busy. Go along with the client's thought of it having been a busy day, but do not refer to the client's work. Reorient the client that the client is at home and did not go to work. Give the client 5 to 10 minutes of rest, and the client will have no memory of the incident.
Go along with the client's thought of it having been a busy day, but do not refer to the client's work.
The client is an 84-year-old suffering from delirium. The client has been in a nursing home for the past 2 years but recently is becoming combative and has become a threat to staff. Which medication would the client most likely receive for these symptoms?
Haloperidol
Which of the following is the primary treatment for delirium?
Identify and treat any casual or contributing medical conditions
A client has been admitted to an inpatient unit for treatment of delirium. Which of the following is the primary treatment for delirium?
Identify and treat any causal or contributing medical conditions
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 then cowers. Which feature of delirium is this client exhibiting?
Illusion
Cognitive disorders are characterized by which of the following?
Impaired attention, memory, and abstract thinking Cognitive mental disorders are characterized by a disruption of or deficit in cognitive function, which encompasses orientation, attention, memory, vocabulary, calculation ability, and abstract thinking. (less)
Acetylcholine
In clients with Alzheimer's disease, neurotransmission is reduced, neurons are lost, and the hippocampal neurons degenerate. Which neurotransmitter is most involved in cognitive functioning?
A client was admitted to an inpatient unit with a diagnosis of dementia. A nursing assessment and interview of the client would include what?
Intellectual ability, health history, and self-care ability
Which of the following medications is not known to cause delirium?
Loop diuretics
Which is the priority intervention for a client diagnosed with delirium?
Maintenance of safety
Which of the following is the priority intervention for a client diagnosed with delirium?
Maintenance of safety
The most effective intervention for clients with delirium is which of the following? Giving detailed explanations Managing environmental stimuli Promoting rest with PRN medications Providing activities for distraction
Managing environmental stimuli
After teaching a group of nursing students about drugs used to treat Alzheimer's disease, the instructor determines that additional teaching is needed when the group identifies which as a N-methyl-D-aspartic acid (NMDA) receptor antagonist?
Memantine
Which of the following is the most consistent and dramatic cognitive impairment seen in dementia?
Memory The most dramatic and consistent cognitive impairment is memory. The mental status assessment can be difficult for clients with dementia because cognitive disturbance is the clinical hallmark of dementia. Deficits in visuospatial tasks that require sensory and motor coordination develop early, drawing is abnormal, and the ability to write may change. Language is progressively impaired. Judgment, reasoning, and the ability to solve problems or make decisions are also impaired later in the disorder, closer to the time of placement in a nursing home. (less)
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?
Monitor amount of environmental stimulation and adjust as needed.
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 of the following interventions should the nurse implement first? Administer an antianxiety drug such as lorazepam (Ativan) at these times Explain the unit routine and the reasons for increased activity to the client. Keep unit activity to a minimum. Move the client to a quieter area during these times.
Move the client to a quieter area during these times.
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?
NMDA receptor antagonist Memantine is classified as an NMDA receptor antagonist that has been shown to improve cognition and activities of daily living in clients with moderate to severe symptoms of dementia. Risperidone, olanzapine, and quetiapine are examples of atypical antipsychotics. Galantamine, donepezil, rivastigmine, and tacrine are cholinesterase inhibitors. Clonazepam, alprazolam, and lorazepam are examples of benzodiazepines. (less)
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?
Oxidative stress
Which assumption made the principles of cognitive behavioral therapies (CBT) is demonstrated by the quote, "For there is nothing either good or bad but thinking makes it so."
People are disturbed not by an event but by the perception of that event. Thoughts have a powerful effect on emotion and behavior. By changing dysfunctional thinking, a person can alter their emotional reaction to a situation and reinterpret the meaning of an event. By thinking a "thing" is "bad" we make it bad is one of the operations tenets of cognitive behavioral therapy (CBT). (less)
A client has experienced a gradual flattening of affect, confusion, and withdrawal and has been diagnosed with Alzheimer's disease. Which additional findings would the nurse most likely assess?
Personality change, wandering, and inability to perform purposeful movements
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 increase the client's agitation.
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 this reluctance?
Physical restraints may increase the client's agitation. The use of physical restraints are usually a last resort for clients with dementia, as restraint use may increase any fears or thoughts of being threatened. The nurse may need to use physical restraints if the patient is pulling at intravenous lines or catheters. Physical restraints do not commonly cause injury to the client or lead to fatality. (less)
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
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
The nurse is assessing a client who is diagnosed with delirium. Which presenting sign in the client indicates to the nurse that the client may may have a diagnosis of dementia?
Remote memory loss Impaired memory may be present in both delirium and dementia. However, remote memory loss and forgetting the names of adult children, their occupations, or even their own names occurs in the later stages of dementia. Irrelevant speech, visual hallucinations, and impaired consciousness are signs of delirium. In dementia, speech is normal at the initial stages and then progresses to aphasia. Hallucinations are less common in dementia. Consciousness is usually not impaired in client with dementia. (less)
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
The nurse is providing care to a client with dementia to meet the client's nutritional needs. Which approach woudl be most appropriate for the nurse to implement to assist in meeting adequate dietary intake? Sit with the client as long as necessary to complete the meal. Provide entertainment during meals such as television or music. Avoid between-meal snacks to encourage appetite. Serve meals in small, bite-size pieces.
Serve meals in small, bite-size pieces.
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?
Signs of delirium
The nurse receives a report that a 75-year-old client recovering from surgery. During the shift, the nurse notes that the client is forgetful and restless. Several times, the client calls the nurse "Audrey", the name of the client's daughter. The nurse interprets this behavior as which of the following?
Signs of delirium Delirium is a syndrome characterized by a rapid onset of cognitive dysfunction and disruption in consciousness. Growing rates of delirium mirror the increasing older adult population and are expected to continue to rise. Delirium is the most common psychiatric syndrome in general hospitals, occurring in up to 50% of elderly inpatients. It is associated with significantly increased morbidity and mortality both during and after hospitalization. (less)
Keisha is a 42-year-old married woman with two children, ages 16 and 18. She is also caring for her mother, who is in the late stages of Alzheimer's disease. The nurse would want to assess Keisha for which of the following?
Signs of stress Nurses must assess family members, especially caregivers, for signs of stress or burnout. Although this issue might not be pertinent during early stages of dementia, it becomes paramount as clients progressively degenerate and demands for physical care mount. (less)
A client is diagnosed with dementia related to Parkinson's disease. While at a clinic visit, a cholinesterase inhibitor is prescribed for the client. The nurse knows that this type of medication would be prescribed for the client to achieve which goal?
Slow deterioration of memory and function
Lewy body dementia
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?
A client is diagnosed with dementia related to Parkinson's disease. While at a doctor's visit, a cholinesterase inhibitor is prescribed for the client. The nurse knows that this type of medication would be prescribed for the client to do which of the following?
Slow deterioration of memory and function Compelling evidence shows that drugs that inhibit ACh destruction or increase cholinergic activity can slow deterioration of memory and function. Cholinesterase inhibitors increase availability of ACh by interfering with the enzyme that breaks it down. These centrally acting drugs help elevate the level of ACh by decreasing the binding sites of acetylcholinesterase, which lengthens the potential for cholineregic activity. (less)
The client is a 79-year-old who has been showing signs of dementia. While the client has some cognitive delays during the day, the client becomes increasingly irritable and experiences hallucinations at night. This phenomenon is known as what?
Sundowning
Which of the following medications, used to treat dementia, requires a liver function test every 1 to 2 weeks?
Tacrine (Cognex)
Haloperidol (Haldol)
The client is an 84-year-old suffering from delirium. The client has been in a nursing home for the past 2 years but recently is becoming combative and has become a threat to staff. Which medication would the client most likely receive for these symptoms?
The psychiatric nurse documents that the cognitively impaired client is exhibiting "confabulation" when observed doing which of the following?
Telling other clients that he "was a dairy farmer" when he actually ran a small grocery store Confabulation is the filling in of memory gaps with false but sometimes plausible content to conceal the memory deficit, such as a client telling others that he "was a dairy farmer" when he actually ran a small grocery store. Evidence of perseveration is a client telling the staff repeatedly that "my name is George and I'm hungry." Sundown syndrome can be described as a client pacing nervously and resisting the staff's request to "get ready for bed." Concrete thinking is described when the client asks where the cats are when told it's "raining cats and dogs." (less)
Provide the client with a tray, opening containers for the client.
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?
An older client comes to the clinic for a yearly physical exam. During the assessment the client tells the nurse that he sometimes has begun feeling anxious about his forgetfulness. The nurse notes the client may have mild dementia. Which finding would lead the nurse to conclude this?
The client has difficulty finding words
An older client comes to the clinic for a yearly physical exam. During the assessment, the client tells the nurse that the client sometimes has begun feeling anxious about the client's forgetfulness. The nurse notes the client may have mild dementia. Which finding would lead the nurse to conclude this?
The client has difficulty finding words
The client is confabulating, most likely to cover for memory deficit.
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?
signs of stress
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?
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.
During morning care, a nursing assistant asks a client with dementia, "How was your night?" The client replies, "It was lovely. My husband and I went out to dinner and to a movie." The nurse, who overhears this conversation, would make which assessment regarding the client?
The client is using confabulation.
During morning care, a nursing assistant asks a client with dementia, "How was your night?" The client replies, "It was lovely. My husband and I went out to dinner and to a movie." The nurse, who overhears this conversation, would make which assessment regarding the client? The client is demonstrating a sense of humor. The client is using confabulation. The client is perseverating. The client is delirious.
The client is using confabulation.
The nurse is assessing a client with aphasia and notes the client may be exhibiting echolalia during their conversation. What signs does the nurse observe that leads to this conclusion?
The client may echo whatever is heard.
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 apraxia.
The nurse asks a client to pretend he is brushing his 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 apraxia. Impaired ability to execute motor functions despite having intact motor abilities is referred to as apraxia. In this case, the client knows how to and has the physical abiltiy to brush his teeth, but is unable to demonstrate the action upon request. Thus the client has apraxia. The inability to recognize or name objects or sounds heard is referred to as agnosia. Aphasia is the deterioration of language function. Disturbed executive function is the inability to carry out complex motor activities. Using a toothbrush is not a complex activity. (less)
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 is convinced that the client sees "hundreds" of bugs and is not always oriented to time and place
The diagnosis of delirium is supported when the nurse notes which in the client?
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 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
The client may have apraxia.
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's diagnosis is primarily based on the rapid onset of the change in consciousness."
The nurse is assessing a client who has received a tentative diagnosis of delirium. The nurse is explaining to the family about the major cause of the client's condition. Which statement by the nurse would be most appropriate?
remote memory loss
The nurse is assessing a client who is diagnosed with delirium. Which presenting sign in the client indicates to the nurse that the client may may have a diagnosis of dementia?
The client may echo whatever is heard.
The nurse is assessing a client with aphasia and notes the client may be exhibiting echolalia during their conversation. What signs does the nurse observe that leads to this conclusion?
Alzheimer's disease
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?
The onset of symptoms of dementia is gradual
The nurse preparing an educational program on dementia should include which information?
Signs of delirium
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?
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 prevent increasing the client's confusion. The nurse understands that too many visitors or more than one person speaking at once may increase the client's confusion. The nurse should also explain to the visitors, that they should speak quietly with the client, one at a time. This may help prevent the client from becoming overstimulated.Talking with many friends at a time doesn't pose a physical danger to the client. While it is ideal for the client to demonstrate proper orientation, it is not the reason the nurse monitors the client's response to visitors. Talking to one person at a time does not help the client maintain an adequate balance of activity and rest. (less)
The nurse preparing an educational program on dementia should include which information?
The onset of symptoms of dementia is gradual
The nurse preparing an educational program on dementia should include which information? The onset of symptoms of dementia is gradual Dementia has many different causes Delirium involves progressive deterioration of intellect Delirium is the most debilitating condition seen in the older population
The onset of symptoms of dementia is gradual
The nurse preparing an educational program on dementia should include which of the following information?
The onset of symptoms of dementia is gradual Dementia refers to a syndrome of global or diffuse brain dysfunction characterized by a gradual, progressive, chronic deterioration of intellectual function.
Distract the client with family photos and discuss the events pictured.
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?
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 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 decrease agitation Haloperidol is usually given to clients with delirium when they become extremely aggressive. The main purpose of the drug is to reduce agitation, not to sedate the client. Haloperidol does not improve the client's appetite. The nurse should provide adequate nutritious food and fluid intake to improve the health of the client. Benzodiazepines are used instead of haloperidol if delirium is induced by alcohol withdrawal. (less)
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, "I feel like all my work doesn't do them any good." Which suggestion would be most appropriate for the supervisor to make initially? Cease giving instructions because the clients will not remember them anyway. Try to stay supportive and meet the clients' needs at the current moment. Seek counseling if personal feelings get in the way of client care. Consider transferring to a different client care specialty area.
Try to stay supportive and meet the clients' needs at the current moment.
To manage voiding issues, such as incontinence, male clients diagnosed with dementia would best be managed by what?
Use of disposable, adult diapers
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
A woman in her fifties has contacted her HCP because of concerns for her husband, who has suddenly begun behaving uncharacteristically in recent days. Most recently, he became lost while driving to his home of 30 years and temporarily forgot his son's name. Diagnostic testing has ruled out delirium and he has been previously healthy. What is the most likely cause of the husband's cognitive changes?
Vascular dementia
Delirium can be differentiated from many other cognitive disorders in which of the following ways?
has a rapid onset and is highly treatable if diagnosed quickly. Delirium often is caused by an acute disruption of brain homeostasis. When the cause of that disruption is eliminated or subsides, the cognitive deficits usually resolve within a few days or sometimes weeks. Dementia, in contrast, results from primary brain pathology that usually is irreversible, chronic, progressive, and less amenable to treatment. (less)
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?
Visual
Which type of hallucination is most commonly seen in clients diagnosed with delirium?
Visual
Which type of hallucination is most commonly seen in clients diagnosed with delirium? Visual Auditory Gustatory Autonomic
Visual
Which type of hallucination most commonly occurs in clients diagnosed with dementia?
Visual Visual, rather than auditory, hallucinations are the most common in those with dementia. Auditory, gustatory, and olfactory hallucinations are not the most common type seen in people with dementia. (less)
provides interaction with those with similar concerns
What is the greatest benefit support groups provide to the caregivers of clients diagnosed with dementia?
observe the client in order to identify the triggers for the delusions
What is the initial intervention the nurse should implement when helping a client diagnosed with dementia deal with paranoid delusions?
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?
Asking a family member to be present during the assessment
When conducting a nursing assessment of a client experiencing moderate cognitive dysfunction, the nurse can best prepare for an effective interview by ensuring what?
Because the liver is most vulnerable to tacrine, liver function tests must be done periodically.
When giving tacrine to an elderly client, the nurse must be aware of what information?
The nurse is assessing the orientation of a client who belongs to the religious group Jehovah's Witnesses. Which questions should the nurse ask this client? Select all that apply.
Where is your residence located? What is your mother's name? Where is your workplace located?
short-term memory loss
Which can be identified as a hallmark symptom of dementia?
Pneumonia
Which is an infection-related cause of delirium?
visual
Which type of hallucination most commonly occurs in clients diagnosed with dementia?
Which client behavior should the nurse attempt to change when managing a client's tendency to wander and pace at night?
take a nap mid afternoon and before dinner Clients with dementia often experience disturbed sleep-wake cycles; they nap during the day and wander at night. This behavior can contribute to the nighttime activity. The other options are not likely to affect sleep cycles. (less)
The client is brought to the clinic with dementia and is unable to recognize ordinary objects, such as a pen or notebook. The family is upset and concerned. The nurse notes that this is a symptom of: agnosia. amnesia. apraxia. aphasia.
agnosia.
The nurse documents that a client diagnosed with dementia of the Alzheimer's type is exhibiting agnosia when the client is observed being unable to ...
identify a picture of a car.
What is the initial intervention the nurse should implement when helping a client diagnosed with dementia deal with paranoid delusions?
observe the client in order to identify the triggers for the delusions Clients with dementia may believe that their physical safety is jeopardized; they may feel threatened or suspicious and paranoid. These feelings can lead to agitated or erratic behavior that compromises safety. Avoiding direct confrontation of the client's fears is important. Clients with dementia may struggle with fears and suspicion throughout their illness. Triggers of suspicion include strangers, changes in the daily routine, or impaired memory. The nurse must discover and address these environmental triggers rather than confront the paranoid ideas. (less)
A nurse is caring for a client with delirium who is experiencing illusions. What environmental conditions should the nurse arrange for this client? provide a well-lit room without glare or shadows and limit noise have the client sit by the nurse's desk while awake in a room with the television on light the room brightly around the clock and awaken hourly to check mental status keep the room shadowy with soft lighting around the clock, and keep a radio on continuously
provide a well-lit room without glare or shadows and limit noise
A nurse is caring for a client with delirium who is experiencing illusions. What environmental conditions should the nurse arrange for this client?
provide a well-lit room without glare or shadows and limit noise Clients with delirium have difficulty paying attention, are easily distracted and disoriented, and may have sensory disturbances such as illusions, misinterpretations, or hallucinations. A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a client with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations. (less)
What is the greatest benefit support groups provide to the caregivers of clients diagnosed with dementia?
provides interaction with those with similar concerns 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. While the other options suggest accurate results, none are the greatest benefit such a support group experience can provide. (less)
Which of the following can be identified as a hallmark symptom of dementia?
short-term memory loss. As a broad diagnosis, dementia includes conditions in which short-term memory loss is a hallmark. The deterioration of memory is so great that it prevents clients from functioning at previous levels of social and occupational performance and seriously deters them from learning new information. (less)
A client was admitted to the intensive care unit after a motor vehicle accident. The client sustained a right parietal injury, resulting in an acute confusional state or delirium. The client reports that there are "bugs crawling around" on the arms. The nurse understands this as: preexisting schizophrenia. tactile hallucinations from delirium. increasing brain damage and poor prognosis. a predisposition to such episodes early in the morning.
tactile hallucinations from delirium.
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 older widower who is worried about his wife not being able to visit because of the snow
The nurse is assessing the orientation of a client who belongs to the religious group Jehovah's Witnesses. Which question should the nurse ask this client? Select all that apply.
• Where is your residence located? • What is your mother's name? • Where is your workplace located? Explanation: People from different cultural backgrounds may not be familiar with the information requested to assess memory. People belonging to the Jehovah's Witnesses religious group do not celebrate birthdays, thus they may have difficulty stating their date of birth and the nurse may mistake the failure to know such information for impaired orientation. Questions about the location of the client's residence or workplace and about the client's mother's name can be asked this client while assessing for orientation. (less)
