Cognition and Sensory
A 51-year-old woman who was born congenitally blind and deaf is able to distinguish individuals by light touch of the individual's face. Which component of the woman's skin innervation likely contributes the most to this ability? Ruffini corpuscles Meissner corpuscles Pacinian corpuscles Nociceptors
Meissner corpuscles Meissner corpuscles are rapidly adapting nerve endings located on the palmar surfaces of the fingers and hands; as such, they would be likely to be involved in fine distinction using the fingers.
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. The ability of clients to care for themselves decreases as the severity of the cognitive order increases. Caregivers can help by enhancing the client's environment to facilitate his or her limited ability to perform activities of daily living and instrumental activities of daily living and by fulfilling unmet client needs.
The nurse is obtaining the history from the parents of an infant who is suspected of having infantile glaucoma. Which statement by the parents would help to confirm this suspicion? "It seems like bright lights really bother him." "He opens his eyes quite frequently when he's awake." "His eye looks about the same size as his other eye." "His eye doesn't seem to tear much."
"It seems like bright lights really bother him." Photophobia occurs with infantile glaucoma, so bright light may bother the infant. Typically, the infant with infantile glaucoma will keep his eyes closed most of the time. The affected eye may appear enlarged with infantile glaucoma. Tearing is associated with infantile glaucoma.
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 Agnosia is the failure to recognize or identify objects despite intact sensory function
Which term is used to describe the inability to execute motor functioning, despite intact motor abilities? Apraxia Aphasia Agnosia Executive functioning
Apraxia Apraxia is the impaired ability to execute motor functions despite intact motor abilities.
The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began? Shortness of breath Sensitivity to bright light Muscle spasms Drooping eyelids
Drooping eyelids Ptosis (eyelid drooping) is the most common manifestation of myasthenia gravis. Muscle weakness varies depending on the muscles affected
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? Hypertension Heart disease Hyperlipidemia Diabetes
Hypertension Vascuar neurocognitive disorder involves a series of small strokes that damage or destroy brain tissue. The primary causes of these strokes include high blood cholesterol levels, diabetes, heart disease, and high blood pressure. Of these, high blood pressure is the greatest risk factor for vascular neurocognitive disorder.
Which medication is not known to cause delirium? Loop diuretics Steroids Narcotics Antidepressants
Loop diuretics Explanation: Loop diuretics are not known to causes delirium. Steroids, narcotics, and antidepressants may cause delirium.
Which nursing diagnosis would best apply to a child with allergic rhinitis? Pain related to sinus edema and headache Ineffective tissue perfusion related to frequent nosebleeds Disturbed self-esteem related to inherited tendency for illness Risk for infection related to blocked eustachian tubes
Pain related to sinus edema and headache Many children with allergic rhinitis develop sinus headaches from edema of the upper airway. In younger children the maxillary and ethmoid sinuses are involved. In children aged 10 years and older the frontal sinuses are also involved. The pain comes from mucosal swelling, decreased ciliary movement and a thickened nasal discharge.
A nurse is completing the history and physical examination of an older adult patient. When assessing the pateint's eyes, which of the following would the nurse document as a normal finding? Reports of being sensitive to glare Brisk pupillary dilation when tested Holds reading material close to face Inability to distinguish several colors
Reports of being sensitive to glare In the older adult, normal age-related changes include a sensitivity to glare, the need to hold objects, such as reading materials, far away from the face, slowed pupil dilation, and difficulty discerning blue from green.
Which test would be used to determine an inner ear dysfunction? Romberg test tympanometry pure-tone testing acoustic reflex testing
Romberg test A Romberg test is used to evaluate a person's ability to sustain balance. Because central nervous system lesions cause similar abnormal results, additional testing is needed to confirm inner ear dysfunction. Tympanometry assists in detection of fluid in the middle ear. Pure-tone testing determines the faintest tones a person can hear and is a test of the middle ear. Acoustic reflex testing is done to assess the loudness level at which the acoustic reflex occurs and is a test of the
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. Features of delirium may include a reduced level of consciousness, a disrupted sleep-wake cycle, and an abnormality of psychomotor behavior. The hospitalized client with delirium will try to remove intravenous lines and other tubes, "pick" at the air or the bed sheet, and try to climb over side rails or the end of the bed.
The nurse is caring for a client who has been in labor for the past 8 hours. The nurse determines that the client has transitioned into the second stage of labor based on which sign? Emotions are calm and happy. Frequency of contractions are 5 to 6 minutes. Fetus is at -1 station. The urge to push occurs.
The urge to push occurs. Second stage of labor is the pushing stage; this is typically identified by the woman's urge to push or a feeling of needing to have a bowel movement. In the second stage the cervix can be 10 cm, dilated 100% and effaced. The station is usually 0 to +2. The emotional state may be altered due to pain and pressure. Contraction frequency is variable and not clearly indicative of a particular stage. The fetus can be at stage -1 for any length of time.
A client prescribed COC has presented for a routine visit. Which finding upon assessment should the nurse prioritize? abdominal pain small amount of breakthrough bleeding light menstrual flow cramping during menses
abdominal pain The warning signs to report for a client on oral contraceptives are severe abdominal or chest pain, dyspnea, headache, weakness, numbness, blurred or double vision, speech disturbances, or severe leg pain and edema. Light bleeding, light flow, and cramping are all normal.
The nurse is monitoring a client during moderate sedation. The client is laying on the gurney with eyes closed and opens the eyes and moans when the nurse touches the shoulder, but not when the nurse says the client's name. The nurse charts the client responds to what type of stimuli? spontaneous verbal tactile painful
tactile This client is responsive to tactile stimulation, because the client responded when the nurse touches the skin. Spontaneous response would refer to the client who was awake, alert, and required no intervention on the nurse's part to elicit a response. If the client had responded to the nurse saying the client's name, this would be a response to verbal stimuli. The client does not require painful stimuli, such as nail bed pressure, trapezius squeeze, or sternal rub, to get a response.
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 Hallucinations occur frequently in dementia and are usually visual or tactile (they can also be auditory, gustatory, or olfactory). Visual, rather than auditory, hallucinations are the most common type in people with dementia.
In myasthenia gravis (MG), there is a decrease in the number of receptor sites of which neurotransmitter? Acetylcholine Epinephrine Norepinephrine Dopamine
Acetylcholine In MG, there is a reduction in the number of acetylcholine receptor sites because antibodies directed at the acetylcholine receptor sites impair transmission of impulses across the neuromuscular junction. T
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 Achievement of self-esteem needs would not be a primary goal of nursing care for the client diagnosed with delirium. All other options would be primary goals.
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 Protection from injury Management of confusion Addressing physiological and psychological needs
Achievement of self-esteem needs The primary goal of treatment of individuals with delirium is prevention or resolution of the acute confusional episode with return to previous cognitive status and interventions focusing on (1) elimination or correction of the underlying cause and (2) symptomatic and safety and supportive measures. Self-esteem is not an issue with delirium.
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. At times, there may seem to be no way to resolve the emotional frustration, agitation, or outbursts of the client who is angry with the environment and those in it. The caregiver might find it beneficial to redirect or distract the client. This can be done by asking to see a client's personal items, such as photographs, and then talking about the family members and life events illustrated by the photographs in the book.
A client with chronic renal failure complains of generalized bone pain and tenderness. Which assessment finding would alert the nurse to an increased potential for the development of spontaneous bone fractures? Elevated serum creatinine Hyperkalemia Hyperphosphatemia Elevated urea and nitrogen
Hyperphosphatemia Osteodystrophy is a condition in which the bone becomes demineralized due to hypocalcemia and hyperphosphatemia.
A client on an acute medicine unit with a diagnosis of small bowel obstruction is reporting intense, diffuse abdominal pain. Which physiologic phenomenon is most likely contributing to the client's pain? Nociceptive afferents are conducting along the cranial and spinal nerve pathways of the ANS. First-order neurons are inappropriately signaling pain to the dorsal root ganglion. The client is experiencing neuropathic pain. An overlap of nerve fiber distribution between the dermatomes is causing the pain.
Nociceptive afferents are conducting along the cranial and spinal nerve pathways of the ANS. Visceral pain, as characterized by the client's description of her pain, is conducted by way of nociceptive afferents that use the cranial and spinal nerve pathways of the ANS. The problem is not likely rooted in the inappropriate firing of first order neurons or the substitution of conduction by C fibers. Pain that is attributable to a pathologic process apart from the neural pain network is not normally considered to be neuropathic. An overlap of nerve fiber distribution between the dermatomes occurs with cutaneous pain, not visceral pain.
Hypothalamic sensory neurons that promote thirst when stimulated are called: Baroreceptors Chemoreceptors Thermoreceptors Osmoreceptors
Osmoreceptors Sensory neurons, called osmoreceptors, which are located in or near the thirst center in the hypothalamus, respond to changes in the osmolality of extracellular fluid by swelling or shrinking.
A older adult client develops delirium secondary to an infection. Which would be the most likely cause? Pneumonia Cellulitis Low platelet count Appendicitis
Pneumonia Delirium in the older adult is associated with medications, infections, fluid and electrolyte imbalance, metabolic disturbances, or hypoxia or ischemia. Infections of the respiratory tract such as pneumonia or urinary tract are the most common
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 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.
Loud, persistent noise has been found to cause which symptoms? constriction of peripheral blood vessels. increased blood pressure. increased heart rate. decreased gastrointestinal activity.
constriction of peripheral blood vessels. Loud, persistent noise has been found to cause constriction of peripheral blood vessels, increased blood pressure, increased heart rate, and increased gastrointestinal motility.
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. Agnosia is the failure to recognize or identify objects despite intact sensory function, so the nurse documents that a client diagnosed with dementia of the Alzheimer's type is exhibiting it when the client is observed being unable to identify a picture of a car. Apraxia is the impaired ability to carry out motor activities despite motor function; aphasia is the presence of language disturbance; and disturbances in executive functioning manifest in things like the inability to open a juice container.
A nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding requires immediate intervention? more back pain than the first postoperative day paresthesia in the dermatomes near the wounds urine retention or incontinence temperature of 99.2° F (37.3° C)
urine retention or incontinence Urine retention or incontinence may indicate cauda equina syndrome, which requires immediate surgery.
The nurse understands that movement of otoliths may result in: vertigo and nystagmus. severe otalgia. permanent hearing loss. inability to hear high-pitched frequencies.
vertigo and nystagmus. Movement of the otoliths or free-floating debris causes the vestibular system to become more sensitive, such that any movement of the head in the plane parallel to the posterior duct may cause vertigo and nystagmus.
The nurse is talking with the mother of a 4-year-old boy who will soon be going to a pre-kindergarten program. The child has had the Snellen vision test done at home, and he was unable to distinguish the pictures at the distance that would indicate his vision is normal. The child's mother asks the nurse if he will need glasses. Which statement made by the nurse would be mostappropriate regarding the child's vision? "He might be suffering from hyperopia and probably will need glasses now." "Children's vision is not completely developed by this age. Your child might outgrow this nearsightedness." "He is likely to have a slight astigmatism, which almost always needs to be corrected by glasses." "His vision problem will get in the way of his learning, so he will probably have to have glasses before he starts school."
"Children's vision is not completely developed by this age. Your child might outgrow this nearsightedness." Visual acuity of children gradually increases from birth, when the visual acuity is usually between 20/100 and 20/400, until about 5 years of age, when most children have 20/20 vision.
The nurse is educating a client who has been prescribed atropine, an anticholinergic drug. Which instructions should the nurse provide to the client? "Do not drive or operate machinery." "If you experience eye pain, contact the health care provider about increasing the dosage." "Increase your fluid intake and activity level." "Take long, hot showers frequently to relieve uncomfortable side effects."
"Do not drive or operate machinery." Effects of anticholinergic drugs such as atropine include blurred vision and impaired ability to sweat. Clients should be cautioned to avoid activities that may be made dangerous by blurred vision; this may include driving and operating machinery. To avoid overheating, clients should avoid strenuous activity and take other measures to stay cool (e.g., frequent cool baths). Clients experiencing eye pain may have undiagnosed glaucoma; they should stop taking the medications and contact their health care providers.
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?" "Are you aware of your parent falling or injuring the head in any way?" "Has your parent had a recent stroke?" "Has your parent experienced any major losses recently?"
"Has your parent taken any medications recently?" Delirium is typically caused by medications, urinary or upper respiratory tract infections, fluid and electrolyte imbalances, and metabolic disturbances. Therefore, questioning the adult child about the client's medication use would be most appropriate. Head injury or stroke may lead to changes in consciousness but not delirium. Although acute or chronic stress may be a risk factor for the development of delirium, this would not be the most appropriate question to ask at this time.
A child has been diagnosed with bacterial conjunctivitis. Which statements by the child's parent indicate the need for further education? Select all that apply. "I'll continue to use eye drops to help with the redness." "All of us at home need to wash our hands really well." "We should not use a towel that he has used." "He can go back to school in 4 hours after that thick yellow drainage is gone." "This is really contagious."
"I'll continue to use eye drops to help with the redness." "He can go back to school in 4 hours after that thick yellow drainage is gone." Eye drops are not appropriate to use because rebound vasoconstriction may occur and it is not actually treating the infection. The child can go back to school 24 to 48 hours after the mucopurulent drainage is no longer present.
The advance practice nurse is treating a client experiencing a neuropathic pain syndrome. Which statements by the client demonstrates an understanding of concepts related to neuropathic pain? "Neuropathic pain will only last a few days and is easily treated with COX-2 analgesic agents." "Neuropathic pain is the body's normal response to tissue damage that causes pain." "When the inflammation in my foot resolves, I will no longer have pain from neuropathy." "My phantom limb pain serves no purpose, and I may need to take antidepressants to help."
"My phantom limb pain serves no purpose, and I may need to take antidepressants to help." Neuropathic pain is an abnormal processing of sensory input by the peripheral or central nervous system or both. Neuropathic pain may occur in the absence of tissue damage and inflammation. Neuropathic pain serves no useful purpose. Evidence-based guidelines recommend the tricyclic antidepressants despiramine (Norpramin) and nortriptyline (Aventyl, Pamelor) and the SNRIs duloxetine (Cymbalta) and venlafaxine (Effexor) as first-line options for treatment of neuropathic pain.
The nurse is performing assessments for clients admitted in the emergency department. Which client is most likely experiencing somatic pain? A client suspected to have a perforated peptic ulcer A client who has a sprained ankle A client with chest pain who is having a myocardial infarction A client who has appendicitis
A client who has a sprained ankle Somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain. Visceral pain, or splanchnic pain, is poorly localized and originates in body organs in the thorax, cranium, and abdomen.
On ocular examination, the health care provider notes severely elevated IOP, corneal edema, and a pupil that is fixed in a semi-dilated position. The nurse knows that these clinical signs are diagnostic of the type of glaucoma known as: Chronic open-angle. Normal tension. Acute angle-closure. Chronic angle-closure.
Acute angle-closure. Acute angle-closure glaucoma is characterized by the symptoms listed, as well as by being rapidly progressive and accompanied by pain.
During the health history of a 2-week-old neonate, the nurse discovers the child has not yet had a hearing screening. What test should the nurse schedule? Auditory brain stem response test Rinne test Weber test Tympanometry
Auditory brain stem response test Auditory brain stem response (ABR) test and the evoked otoacoustic emissions (EOAE) test are indicated for newborns. A child not screened for hearing at birth should be screened before 1 month of age. The Rinne and Weber tests are used with children 6 years and older. Tympanometry is appropriate for children beyond 7 months of age.
A nurse is assessing a client and determines that the client is experiencing severe anxiety based on which finding? A heightened sense of awareness Distorted sensory awareness Goal directed behavior Eagerness for more information
Distorted sensory awareness In severe anxiety, perception becomes increasingly distorted, sensory input diminishes, and processing of sensory stimuli becomes scattered and disorganized
The nurse is caring for a client who just returned from a trip requiring an airline flight. The client commented on how his ears hurt upon descent. The nurse is correct in stating which site as being the pressure equalizer in the ear? Eustachian tube Auricle Tympanic membrane Labyrinth TAKE ANOTHER QUIZ
Eustachian tube The eustachian tube extends from the floor of the middle ear to the pharynx. It equalizes air pressure in the middle ear. T
Delirium can be differentiated from many other cognitive disorders in which way? -It has as a slow onset, but if caught early it can be treated with medications. -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 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.
During an eye assessment the nurse notes inflammation of the client's cornea. The nurse should document this as which condition? Keratitis Arcus senilis Uveitis Conjunctivitis
Keratitis Keratitis, or inflammation of the cornea, can be caused by infections, hypersensitivity reactions, ischemia, trauma, defects in tearing, or trauma.
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 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.
The nurse is caring for a client with delirium. Which interventions may help manage this client? Select all that apply. Speak in simple sentences. Encourage the client to follow a regular routine. Use matter-of-fact approach when assuming tasks the client can no longer perform. Provide orienting verbal cues when talking with the client. Allow adequate time for the client to comprehend and respond.
Speak in simple sentences. Provide orienting verbal cues when talking with the client. Allow adequate time for the client to comprehend and respond. To manage the client's confusion, the nurse should use simple sentences and provide verbal cues when talking with the client. The nurse also should allow adequate time for the client to comprehend and respond to any questions. Using a matter-of-fact approach when assuming tasks the client can no longer perform and encouraging the client to follow a regular routine are nursing interventions for dementia.
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 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. A client suffering from aphasia may exhibit echolalia, or echoing what is heard during conversation. Clients who repeat words and sounds over and over are suffering from palilalia. Difficulty forming sentences and producing vague speech that is difficult to interpret can be seen in clients with dementia.
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 is ashamed that the client is unemployed and is trying to cover for it. The client may have Alzheimer's disease. The client may be going through alcohol withdrawal. The client may have Korsakoff's syndrome.
The client may have Korsakoff's syndrome. Korsakoff's syndrome usually is found in the 40- to 70-year-old client with alcoholism and a history of steady and progressive alcohol intake. In time, this person develops a vitamin B1 (thiamin) deficiency that directly interferes with the production of the brain's main nutrient, glucose, resulting in the symptomatology of this syndrome. A client with this disorder has great difficulty with recent memory, specifically the ability to learn new information. Because of the inability to recall recent events, the individual fills in memory gaps with fabricated or imagined data (confabulation).
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 agnosia. The client may have aphasia. The client may have apraxia. The client may have disturbed executive function.
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 the client's 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.
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. 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. Safety is always the nurse's first priority; clients with dementia often cannot meet their basic physical needs and agitation is a common emotional response to confusion and disorientation.
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 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 and 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.
Children feel pain just as much as adults do. What is the major principle in pain management in the pediatric population? Treat on individual basis and match analgesic agent with cause and level of pain. Always use nonpharmacologic pain management before using pharmacologic pain management. Base treatment of pain on gender and age group. Treat pediatric pain the way the parents want it treated.
Treat on individual basis and match analgesic agent with cause and level of pain. The overriding principle in all pediatric pain management is to treat each child's pain on an individual basis and to match the analgesic agent with the cause and the level of pain.
A client was involved in a motor vehicle collision. The client's left arm was severely traumatized in the accident and the client was taken immediately to surgery. Postoperatively, the physician has ordered close monitoring for compartment syndrome. What musculoskeletal structure does compartment syndrome affect? nerve ligament bone All options are correct.
nerve With compartment syndrome, tissue perfusion in the muscle compartment is compromised secondary to tissue swelling, hemorrhage, or a cast that is too tight. If circulation is not restored, ischemia and tissue anoxia lead to permanent nerve damage, muscle atrophy, and contracture.
What is the initial intervention the nurse should implement when helping a client diagnosed with dementia deal with paranoid delusions? -explain to the client that his or her fears are unfounded -observe the client in order to identify the triggers for the delusions -ask that the client be prescribed medication to help manage the paranoia -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 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.
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 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.
When communicating with a client who has sensory (receptive) aphasia, the nurse should: allow time for the client to respond. speak loudly and articulate clearly. give the client a writing pad. use short, simple sentences.
use short, simple sentences. Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension.
