Prep u Chapter 72/ Med Surge
An older client has developed influenza. Three days into the illness the client became disoriented and confused, and didn't recognize family members. What would the nurse suspect is occurring?
delirium
A client has gradually been losing cognitive function and is understandably fearful. What would the physician likely diagnose?
dementia
A nurse should closely monitor a client taking clozapine because clozapine:
depresses bone marrow function.
The nurse observes a client with schizophrenia sitting alone, laughing occasionally, and turning his head as if listening to another person. The nurse assesses this behavior to indicate that the client is experiencing auditory hallucinations and says
"Are you hearing something?"
A nurse approaches the nurses' station, a client diagnosed with a delusional disorder raises his voice and says, "You're following me. What do you want?" To prevent escalating fear and anger, the nurse takes a nonthreatening posture and makes which response in a calm voice?
"I'm sorry if I frightened you. I was returning to the nurses' station after going out for lunch."
The nurse is working with a client with schizophrenia, disorganized type. It is time for the client to get up and eat breakfast. Which of the following statements by the nurse would be most effective in helping the client prepare for breakfast?
"It's time to put your dress on now."
A client asks a nurse if she hears the voice of the nonexistent man speaking to him. Which response is best?
"No, I don't hear him, but I know you do. What's he saying?"
A 49-year-old client is admitted to the emergency department frightened and reporting that he's hearing voices telling him to do bad things. Which intervention should be the nurse's priority?
Assess the nature of the commands by asking the client what the voices are saying.
Which action by a client with stable schizophrenia is most important for preventing relapse?
Consistently taking prescribed medications
Which of the following is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener?
Word salad
The drug haloperidol, used with schizophrenia, exerts its actions by blocking postsynaptic dopamine receptors. The older client must be monitored while on haloperidol because of the potential for:
dehydration and aspiration.
Symptoms of schizophrenia are classified as positive symptoms and negative symptoms. Which symptom would be classified as a negative symptom?
inability to express emotions
Which drug is not an antipsychotic medication?
memantine
An independent older client has developed influenza. Three days into the illness the client became disoriented and confused, and didn't recognize family members. What action would the physician likely take?
treat the underlying condition
A client has been demonstrating progressing symptoms of Alzheimer's disease. The client's spouse has been the primary caregiver with minimal help from the family. The client sleeps only two hours a night and spends a significant amount of the remaining 22 hours a day wandering the house checking to see if the doors are locked. What is an activity that could be offered to the client to distract from wandering?
viewing old photographs
An older adult client who is confused is going to be treated with donepezil (Aricept). This drug is effective in treating clients:
with early-stage Alzheimer's disease.
The nurse enters the room of a client with schizophrenia the day after he has been admitted to an inpatient setting and says, "I would like to spend some time talking with you." The client stares straight ahead and remains silent. The best response by the nurse would be:
"You don't need to talk right now. I'll just sit here for a few minutes."
The nurse is working with a client who has hallucinations and delusions. The client tells the nurse she can't take a shower because she's waiting for her husband to take her home. Which of the following responses by the nurse is best in this situation?
"You have plenty of time to shower before it's time to go home."
A client with Alzheimer's disease has random violent outbursts, wanders, and is incontinent. The client can no longer identify people who were once familiar, and is unable to identify common objects. The nurse should give highest priority to which aspects during care planning?
Risk for injury.
A client diagnosed with schizophrenia tells the nurse, "I hear the voice of Elvis." Which of the following is the most therapeutic response by the nurse?
"I don't hear the voice, but I know you hear what sounds like a voice."
One evening, a client with schizophrenia leaves his room and begins marching in the hall. When approached by the nurse, the client says, "God says I'm supposed to guard the area." Which of the following responses would be best?
"I understand you hear a voice. You and I are the only ones in the hall, and I don't hear a voice."
A 73-year-old man has been brought to the emergency department by his daughter and son-in-law 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 of the following teaching points about the client's diagnosis should the nurse provide to his family?
"If the underlying cause of delirium is identified and treated, most people return to their previous level of functioning."
The nurse enters the room of a client with schizophrenia the day after he has been admitted to an inpatient setting and says, "I would like to spend some time talking with you." The client stares straight ahead and remains silent. The best response by the nurse would be: The nurse enters the room of a client with schizophrenia the day after he has been admitted to an inpatient setting and says, "I would like to spend some time talking with you." The client stares straight ahead and remains silent. The best response by the nurse would be:
"You don't need to talk right now. I'll just sit here for a few minutes."
Which term describes an inability to recognize or name objects despite intact sensory abilities?
Agnosia
A nurse is caring for a client with delirium. What should the nurse assess for in this client?
Altered level of consciousness
During the initial interview, a schizophrenic client states to the nurse, "I don't enjoy things anymore. I used to love to read mystery books, but even that isn't enjoyable now." The nurse correctly identifies the client is experiencing which of the following conditions?
Anhedonia
Which term is used to describe deterioration in language function?
Aphasia
A client has been diagnosed with dementia and is exhibiting several cognitive disturbances. Which term is used to describe the inability to execute motor functioning despite intact motor abilities?
Apraxia
A client is admitted with schizophrenia and episodic delusions. The therapeutic team identifies strategies for working with the client on the unit. What would be a potential barrier for intervention strategies when working with a client in a pronounced delusional state?
Attempting to define reality for the client.
Noncompliance with drug therapy is the leading cause of the return of disease symptoms and the need for short-term hospitalization. What techniques are used to increase medication compliance in the schizophrenic client?
Depot injections, or intramuscular injections of antipsychotic drugs in an oil suspension that are gradually absorbed, are administered every 2 to 4 weeks.
One of the nursing diagnoses related to schizophrenia is self-care deficit related to lack of motivation, illogical fears, and emotional withdrawal. The expected outcome of interventions is that the client will independently perform ADLs. What interventions would be performed to help meet this outcome?
Explain where hygiene is performed and how to obtain soap, shampoo, and toothpaste. Direct the client to care for himself or herself at an appropriate time. Praise any worthy accomplishments.
A nurse is caring for a client with dementia. What measure should the nurse employ when communicating with the client?
Give simple, one-step commands
Which cluster of symptoms would indicate schizophrenia?
Hallucinations or delusions and decreased ability to function in society
The nurse is caring for a client with early onset Alzheimer's disease and understands that the disease will progress in what way? Place the answers in the correct order.
Impairment in short-term memory Impairment in long-term memory Incidents of violent reactions Inability to recognize objects and sounds Inability to accomplish activities of daily living
A client is admitted with a diagnosis of paranoid schizophrenia. The student nurse asks the charge nurse about the approach to take with the client, who has been exhibiting hostility and isolation. Which approach would be the most appropriate direction from the charge nurse?
Respect the client's need for personal space and avoid physical contact.
Which condition is not a characteristic of schizophrenia?
memory loss
What impact could a parent's diagnosis of Alzheimer's disease have on the liklihood of their children developing the disease?
nearly doubles
Which of the following life-threatening reactions, related to neuroleptic medication, is exhibited by rigidity, fever, hypertension, and diaphoresis?
neuroleptic malignant syndrome
Which class of drugs is not used with Alzheimer's disease?
neuroleptics
Which action by the nurse is an appropriate therapeutic intervention for a client experiencing hallucinations?
Providing a competing stimulus that distracts from the hallucinations
A client diagnosed with schizophrenia is laughing and talking while sitting alone. Which of the following is the best response by the nurse?
"Tell me what's happening."
A client with schizophrenia is reluctant to take his prescribed oral medication. The most therapeutic response by the nurse to this refusal is:
"What is it about the medicine that you don't like?"
Since there are no diagnostic tests that are specific for Alzheimer's disease, how is this diagnosis determined?
-All choices are correct. -Other causes for the client's symptoms are excluded. -A computed tomography scan shows shrinking of the cerebral cortex in later stages. -Positron emission tomography and magnetic resonance imaging provide structural and metabolic information. -Electroencephalography detects slower-than-normal brain waves.
Since there are no diagnostic tests that are specific for Alzheimer's disease, how is this diagnosis determined?
-All choices are correct. -Other causes for the client's symptoms are excluded. -A computed tomography scan shows shrinking of the cerebral cortex in later stages. -Positron emission tomography and magnetic resonance imaging provide structural and metabolic information. -Electroencephalography detects slower-than-normal brain waves.
The nurse is caring for a client who has been prescribed rivastigmine (Exelon) 2.5 mg twice a day. The medication is available as rivastigmine (Exelon) 2 mg/mL. How much medication will the nurse administer to the client for one dose?
1.3 mL 2.5 mg/1 x 1 mL/2 mg = 1.25 mL = 1.3 mL
According to the National Institute of Aging, how many stages are typical of the progression of Alzheimer's disease?
3
Where is Alzheimer's disease ranked in the top 20 causes of death in the United States?
6th
A client is sitting in the day room/dining area and laughing out loud, shaking his head, and whispering behind his hand. Suddenly he begins banging his head against the wall. Which of the following interventions is most appropriate?
Calmly walk over to the client and say, "Tell me what's going on."
The nurse can distinguish delirium from dementia by knowing which of the following?
Dementia has a gradual onset and is progressive in course.
A 70-year-old woman is brought to emergency department. She is confused, incoherent, and agitated after reportedly spray painting metal lawn furniture with metal paint earlier that day. She has no history of illness and is not taking any medication. Which of the following assessments would be appropriate for the nurse to make?
Delirium related to toxin exposure.
A client is admitted after being found on a highway, hitting at cars and yelling at motorists. When approached by the nurse, the client shouts, "You're the one who stole my husband from me." Which condition describes the client's condition?
Delusional experience
Which type of therapy involves shifting the client's attention and energy to a more neutral topic?
Distraction
Schizophrenia is theorized to be caused by an excess of which neurotransmitter?
Dopamine
A client is repeating every word that the nurse says. This would be correctly documented as which of the following?
Echolalia
A nurse is caring for a client with schizophrenia who is currently experiencing auditory hallucinations. Which of the following nursing actions should be first priority?
Engaging the client in reality-based conversations.
As a nurse planning care for a client with paranoid delusions, which of the following will be the priority goal?
Establishing trust.
A client with schizophrenia is admitted to the inpatient unit. He does not speak when spoken to but has been observed talking to himself on occasion. At this time, the priority goal for this client is to:
Increase his reality orientation
A nurse is caring for a client with dementia. What measure should the nurse take when assisting the client with nutrition and hydration?
Keep reminding the client to chew and swallow
Schizophrenia is now characterized as a psychobiologic disease because of recent findings in brain and neurotransmitter chemistry. What are two psychobiologic explanations for schizophrenia?
Many neurotransmitter imbalances are involved in schizophrenia. Schizophrenia is known to have a familial or genetic component.
A client, age 84 years, is stopped for going through a red light in a small town where he has lived all his life. He tells the officer, "It wasn't there yesterday." He is unable to tell the officer his address and demonstrates labile mood, seeming pleasant one minute and angry the next. The officer knows that the client is a nice old man, and instead of ticketing him, he takes him home to discuss his condition with the family. The client lives with his wife, who is legally blind. She mentions, "John's my eyes, and I'm his mind." She also relates that the client wanders around the neighborhood occasionally, taking tools from people's garages, saying they belong to him. She reluctantly agrees that the client should be admitted to the psychogeriatric inpatient unit for evaluation. His admitting diagnosis is Alzheimer's disease. Which early symptoms of Alzheimer's disease is the client demonstrating?
Memory disturbance.
Which assessment should a nurse initially perform for a client with schizophrenia?
Mini-Mental State Examination
While talking to a client with schizophrenia, a nurse notes that the client frequently uses unrecognizable words with no common meaning. Which term describes this?
Neologisms
Which of the following life-threatening reactions, related to neuroleptic medication, is exhibited by rigidity, fever, hypertension, and diaphoresis?
Neuroleptic malignant syndrome
Why is important for nurses to assess blood pressure in patients receiving antipsychotic drugs?
Orthostatic hypotension is a common side effect.
A client has experienced a gradual flattening of affect, confusion, and withdrawal and has been diagnosed with Alzheimer's disease. The nurse assesses which of the following additional characteristics of this disorder?
Personality change, wandering, and inability to perform purposeful movements
The nurse understands that clients with cognitive disorders often experience spatial confusion as their diseases progress. Which of the following measures should be undertaken to maximize clients' safety and independence when navigating an inpatient facility?
Post arrows, signs, and paths in the facility and increase lighting.
What is a nurse's role in providing home care for a client with Alzheimer's disease?
Provide emotional and physical support.
When planning care for a client newly diagnosed with Alzheimer's disease, the nurse should focus on:
Providing a safe, structured environment
A client is in the first stage of Alzheimer's disease. The nurse should plan to focus this client's care on:
Providing emotional support and individual counseling
A resident at a long-term care facility is active and independent despite some urinary incontinence. The client is typically alert and oriented but has begun to display confusion and disorientation. What is likely the problem?
UTI
The nurse is working with the family of a client who is newly diagnosed with Alzheimer's type dementia. Which of the following suggestions would be effective for assisting the family in daily orienting of their family member when the client returns home?
Use daily newspapers, calendars, and a set routine.
A client with a medical diagnosis of dementia of Alzheimer's type (DAT) 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?
Use the least restrictive devices if necessary.
A client with schizophrenia is hearing voices that tell him to kill himself. The nurse understands that this client is experiencing
a hallucination
A client with dementia is unable to recognize ordinary objects, such as a pen or notebook. The nurse recognizes this symptom as:
agnosia
Which extrapyramidal side effects (EPS) are associated with traditional antipsychotic drugs?
akinesia akathisia tardive dyskinesia
Which extrapyramidal side effects (EPS) are associated with traditional antipsychotic drugs? Select all that apply.
akinesia akathisia tardive dyskinesia
It is important for a nurse not to argue about the validity of a schizophrenic client's delusions or try and convince him or her that they are wrong because clients may:
become more fixated on their delusions.
The nurse is assessing a client with early signs of dementia. The nurse asks the client what he ate for breakfast that morning. The purpose of this question is to determine which of the following?
recent memory