Mental Health - Prep U - Chapter 24

Which would not be considered a primary goal of nursing care for a client with delirium?

Achievement of self-esteem needs

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

A client diagnosed with Alzheimer's disease has an alteration in language ability. This alteration would be documented as what?

Aphasia

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

Apraxia

Delirium can be differentiated from many other cognitive disorders in which way?

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

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

A client with Alzheimer's disease in the intensive treatment unit repeatedly tries to go into other clients' rooms to nap during the day. The most appropriate nursing intervention for this client is what?

Escorting the client to the client's room for napping

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 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

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 these is a N-methyl-D-aspartic acid (NMDA) receptor antagonist?

Memantine

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.

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 older adult client develops delirium secondary to an infection. Which would be the most likely cause?

Pneumonia

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

Which nursing diagnosis would be the priority for the client experiencing acute delirium?

Risk for injury related to confusion and cognitive deficits

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 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

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 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 preparing an educational program on dementia should include which information?

The onset of symptoms of dementia is gradual

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

To manage voiding issues, such as incontinence, male clients diagnosed with dementia would best be managed by what?

Use of disposable, adult diapers

Which type of hallucination is most commonly seen in clients diagnosed with delirium?

Visual

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

What is the greatest benefit support groups provide to the caregivers of clients diagnosed with dementia?

provides interaction with those with similar concerns

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

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