Mental Health Final Ch. 24

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 experienced any major losses recently?" "Are you aware of your parent falling or injuring the head in any way?" "Has your parent had a recent stroke?" "Has your parent taken any medications recently?"

"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? "Basically, this diagnosis is based on the client's inability to talk normally." "Your report of gradually developing confusion over time was the basis for the diagnosis." "The client's diagnosis is primarily based on the rapid onset of the change in consciousness." "The client's exposure to an infectious agent led us to determine the diagnosis."

"The client's diagnosis is primarily based on the rapid onset of the change in consciousness."

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? "We don't have your clothes; they are at home. You'll be going home when you recover." "It's time to sleep now; you can see your family in the morning." "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."

Which would not be considered a primary goal of nursing care for a client with delirium? Achievement of self-esteem needs Protection from injury Management of confusion Meeting physiological and psychological needs

Achievement of self-esteem needs

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

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? Aphasia Agnosia Apraxia Disturbance of executive function

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? Aphasia Apraxia Agnosia Executive functioning

Agnosia

When assessing a client with dementia, the nurse notes that the client is having difficulty identifying common items, such as a ball or book. The nurse interprets this finding as what? Aphasia Apraxia Agnosia Disturbance of executive function

Agnosia

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? Vascular dementia Alzheimer's disease Parkinson's disease Picks's disease

Alzheimer's disease

The nurse is performing an admission assessment for a client who is suspected of having dementia. Which finding would the nurse most likely document as a subjective finding? Assessment of the client's level of consciousness Client's ability to perform arithmetic problems to determine cortical function Answers by the client and family to questions about emotional changes Results of testing the client's ability to remember unrelated words and recent events

Answers by the client and family to questions about emotional changes

Which term is used to describe the inability to execute motor functioning, despite intact motor abilities? Apraxia Aphasia Agnosia Executive functioning

Apraxia

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.

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? Dementia related to advancing age Depression related to declining health Delirium related to underlying medical problem Transient ischemic attacks related to vascular disease and diabetes

Delirium related to underlying medical problem

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 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. Give the client a sedative when the client begins to get agitated.

Distract the client with family photos and discuss the events pictured.

A client with Alzheimer's disease is admitted to an acute care facility for treatment of an infection. Assessment reveals that the client is anxious. When developing the client's plan of care, which would be least appropriate for a nurse to include? Establish predictable routines Frequently provide reality orientation Simplify the client's routines Limit the number of choices to be made

Frequently provide reality orientation

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? Skin rashes Gastrointestinal (GI) symptoms Bruising Syncope

Gastrointestinal (GI) symptoms

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? Tacrine Rivastigmine Haloperidol Galantamine

Haloperidol

A client with amnestic disorder is being evaluated for dementia. Which is a diagnostic characteristic of amnestic disorder? Memory impairment limited to periods of delirium Memory minimally decreased from usual No significant problems with occupational or social functioning History and physical examination indicative of memory impairment

History and physical examination indicative of memory impairment

A nurse is preparing a presentation for a group of staff nurses about neurocognitive disorders. When describing vascular neuorocognitive disorder, the nurse would identify which as posing the greatest risk for this disorder? Heart disease Hyperlipidemia Diabetes Hypertension

Hypertension

Which is a metabolic cause of delirium? Meningitis Encephalitis Alcohol Intoxication Hypoglycemia

Hypoglycemia

A nurse is caring for a client with delirium. The client sees a thermometer on the nurse's table and shouts, "Don't stab me!" and cowers. Which feature of delirium is this client exhibiting? Euphoria Misinterpretation Illusion Hallucination

Illusion

Delirium can be differentiated from many other cognitive disorders in which way? It is much less responsive to pharmacologic treatment than the other disorders. It has a rapid onset and is highly treatable if diagnosed quickly. It is characterized by a period of disorganization and confusion. It has as a slow onset, but if caught early it can be treated with medications.

It has a rapid onset and is highly treatable if diagnosed quickly.

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? Ensure environmental noise for stimulation. Keep a record of emotional outbursts. Give acetaminophen if the client appears uncomfortable. Keep a record of bowel movements.

Keep a record of bowel movements.

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? Creutzfeldt-Jakob disease Huntington's disease Lewy body dementia Pick's disease

Lewy body dementia

Which medication is not known to cause delirium? Loop diuretics Steroids Narcotics Antidepressants

Loop diuretics

A client with a medical diagnosis of dementia of Alzheimer's type has been increasingly agitated in recent days. As a result, the nurse has identified the nursing diagnosis of "risk for injury related to agitation and confusion" and an outcome of "the client will remain free from injury." What intervention should the nurse use in order to facilitate this outcome? Apply restraints and place the client in seclusion as necessary. Monitor amount of environmental stimulation and adjust as needed. Explain to the client the relationship between agitation and injury. Set limits with the client around behavior.

Monitor amount of environmental stimulation and adjust as needed.

While reviewing the medical record of a client with moderate dementia of the Alzheimer type, a nurse notes that the client has been receiving memantine. The nurse identifies this drug as which type? N-methyl-D-aspartate (NMDA) receptor antagonist Cholinesterase inhibitor Benzodiazepine Atypical antipsychotic

N-methyl-D-aspartate (NMDA) receptor antagonist

A group of nursing students is reviewing information about delirium and its causes. The students demonstrate a need for additional review when they identify which as a cause of this medical condition? Electrolyte imbalance Oxidative stress Infection Medications

Oxidative stress

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? Tremors, unsteady gait, and transient paresthesias Personality change, wandering, and inability to perform purposeful movements Transient blindness, slurred speech, and weakness Uncharacteristic use of illicit substances and alcohol

Personality change, wandering, and inability to perform purposeful movements

An older adult client develops delirium secondary to an infection. Which would be the most likely cause? Pneumonia Cellulitis Low platelet count Appendicitis

Pneumonia

A client is brought to the emergency department by a spouse. The spouse states that over the past few hours, the client has become disoriented and confused. "The client didn't know where the client was and didn't seem to recognize me or be able to carry on a coherent conversation." The nurse suspects delirium. When reviewing the client's medication history with the spouse, which medications would alert the nurse to a potential cause? Select all that apply. Quinidine Acetaminophen Propranolol Verapamil Diphenhydramine

Propranolol Diphenhydramine Quinidine

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. Ask the client what the client would like from the buffet and give the client finger foods. Provide the client with a tray but encourage the client to open the client's own packages. Have the client eat in the client's room to avoid distractions while eating.

Provide the client with a tray, opening containers for the client.

A client is in the mild stage of dementia due to Alzheimer's disease. Which intervention would be most appropriate? Suggesting new activities for the client and family to do together Advocating for the client to be transitioned to a care home Providing emotional support and gentle reminders Offering nourishing finger foods to help maintain the client's nutritional status

Providing emotional support and gentle reminders

A nurse's aide has rung the call light for assistance while providing a client's twice-weekly bath because the client became agitated and aggressive while being undressed. Knowing that the client has a diagnosis of Alzheimer's disease and is prone to agitation, which measure may help in preventing this client's agitation? Decreasing the frequency of the client's baths from two times to one time per week Reminding the client multiple times that he or she will be soon having a bath Reinforcing the facility's zero-tolerance policy for aggressive behavior Providing all of the client's daily medications early on the day of a scheduled bath

Reminding the client multiple times that he or she will be soon having a bath

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 have a diagnosis of dementia? Visual hallucinations Remote memory loss Irrelevant speech Impaired consciousness

Remote memory loss

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

A client is diagnosed with dementia that has progressed significantly. Which would be the priority for this client? Safety Education Support Cognitive interventions

Safety

Which can be identified as a hallmark symptom of dementia? This class of disorders does not involve memory loss Clients with these disorders tend to confabulate Long-term memory affected most Short-term memory loss

Short-term memory loss

The nurse receives a report that a 75-year-old client is recovering from surgery. During the shift, the nurse notes that the client is forgetful and restless. Several times, the client calls the nurse the name of the client's daughter. The nurse interprets this behavior as what? Normal for the first postoperative day Normal, given the client's age Signs of early Alzheimer's disease Signs of delirium

Signs of delirium

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 Increase the number of neurons in the brain Decrease tremors associated with Parkinson's disease Decrease combative behaviors and hallucinations

Slow deterioration of memory and function

Which medication used to treat dementia requires a liver function test every 1 to 2 weeks? Galantamine Tacrine Rivastigmine Donepezil

Tacrine

The psychiatric nurse documents that the cognitively impaired client is exhibiting "confabulation" when observed doing what? Telling other clients that the client "was a dairy farmer" when the client actually ran a small grocery store Telling the staff repeatedly that "my name is George and I'm hungry" Pacing nervously and resisting the staff's request to "get ready for bed" Asking where the cats are when told it's "raining cats and dogs"

Telling other clients that the client "was a dairy farmer" when the client actually ran a small grocery store

The client has early Alzheimer's disease. When asked about family history, the client relates that the client has two children who are both grown and who visit the client around the holidays each year. The nurse subsequently discovers that the client has one child who is currently assigned overseas and who has not been home for 2 years. Which would best describe the client's behavior? The client is showing signs of agnosia in that the client is unable to name the client's children. 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 confabulating, most likely to cover for memory deficit.

The client is confabulating, most likely to cover for memory deficit.

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 repeat words or sounds over and over. The client may have extreme difficulty forming sentences. The client's speech may be vague and cannot be interpreted. The client may echo whatever is heard.

The client may echo whatever is heard.

The nurse is interviewing a 50-year-old with a suspected cognitive disorder. The client has a long history of alcoholism. When the nurse asks if the client is employed, the client replies that the client is currently employed as a conductor on a national railway system. The client's spouse takes the nurse aside and informs the nurse that the client hasn't worked for several years and never worked for the railway. The nurse attributes the client's answer to which explanation? The client may be going through alcohol withdrawal. The client may have Alzheimer's disease. The client may have Korsakoff's syndrome. The client is ashamed that the client is unemployed and is trying to cover for it.

The client may have Korsakoff's syndrome.

The nurse asks a client to pretend the client is brushing the client's teeth. The client is unable to perform the action. Upon examination, the nurse finds that the client possesses intact motor abilities. What can this problem be documented as? The client may have disturbed executive function. The client may have agnosia. The client may have aphasia. The client may have apraxia.

The client may have apraxia.

A 65-year-old has been admitted to the intensive care unit following surgical resection of the bowel. The client has developed a fever. Which additional signs indicate the client has developed delirium? The client cannot brush the client's teeth. The client removes the client's surgical bandage and begins picking at the sheets. The client identifies the client's fork as a spoon. The client has trouble remembering the client's birth date.

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 and eat appropriately. The client will be physically stable, maintain normal body weight, and be safe. The client will have no self-harm behaviors and maintain sleep and appetite. The client will be safe, be physiologically stable, and have infrequent episodes of agitation.

The client will be safe, be physiologically stable, and have infrequent episodes of agitation.

A group of friends have arrived at the hospital to visit a client recently diagnosed with delirium. The nurse tells the friends they can visit with the client one at a time. What is the likely reason for the nurse to give this instruction? The nurse wants to ensure the client's safety. The nurse wants to prevent increasing the client's confusion. The nurse wants the client to demonstrate good orientation. The nurse wants the client to maintain an adequate balance of activity and rest.

The nurse wants to prevent increasing the client's confusion.

After educating a group of nurses on Alzheimer's disease and appropriate nursing care, the group leader determines that the education was successful when the nurses identify which as the foundation for providing care to the client and family? Functional independence Medication therapy Injury prevention Therapeutic relationship

Therapeutic relationship

A nurse is caring for a client with delirium. The nurse assesses the client's activities of daily living on a daily basis. What is the most likely reason for assessing these so frequently? To ensure the client is involved in therapy To ensure the client establishes a daily routine To assess the prognosis of the client after therapy To assess for fluctuation in the client's capabilities

To assess for fluctuation in the client's capabilities

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 client has contacted the care provider because of concerns for the client's 55-year-old spouse, who suddenly became very forgetful in recent days. Most recently, the spouse became lost while driving to the spouse's home of 30 years and temporarily forgot the client's adult child's name. The client also had a temporary slurring of speech lasting about a minute. Diagnostic testing has ruled out delirium and the spouse had been previously healthy. Which would the nurse most likely suspect? Vascular neurocognitive disorder Frontotemporal neurocognitive disorder Alzheimer's disease Neurocognitive disorder with Lewy Bodies

Vascular neurocognitive disorder

When assessing a client with dementia, a nurse identifies that the client is experiencing hallucinations. Based on the nurse's understanding of this disorder, which type of hallucination would the nurse expect as most common? Auditory Visual Gustatory Olfactory

Visual

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 the client is in an unfamiliar environment and overstimulated No, because the client will not be hospitalized long enough to develop delirium No, because the client does not have an underlying disease process Yes, because of the head injury and medication

Yes, because of the head injury and medication

Directed by evidence-based practice, the psychiatric nurse minimizes the milieu's dementia-induced aggressive behavior by: playing music with varied pitches during meal times. adhering to a predictable dressing routine. speaking to the clients in a soft voice. turning the television off at sundown.

adhering to a predictable dressing routine.

Which client behavior should the nurse attempt to change when managing a client's tendency to wander and pace at night? request a bedtime snack of milk and cookies watch television after dinner insist on having the curtains left open at night take a nap mid-afternoon and before dinner

take a nap mid-afternoon and before dinner

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 ... button a blouse. find words to describe the client's daughter's appearance. identify a picture of a car. open juice and insert a straw into the container.

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? keep the client occupied when he or she first begins to express the delusion observe the client in order to identify the triggers for the delusions explain to the client that his or her fears are unfounded ask that the client be prescribed medication to help manage the paranoia

observe the client in order to identify the triggers for the delusions

What is the greatest benefit support groups provide to the caregivers of clients diagnosed with dementia? provides a social outlet provides interaction with those with similar concerns provides resources for needed services provides time away from the client

provides interaction with those with similar concerns

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 adolescent who is hitting and biting because he or she was given time out for disobeying unit rules the middle-aged adult who is convinced that the electrical cords are really snakes the young adult who is expressing concern about the "police being aliens"

the older widower who is worried about his wife not being able to visit because of the snow