MH Exam #3 - Ch 22

The nurse is assessing a client who is diagnosed with Alzheimer's disease (AD) with moderate cognitive decline. Which question does the nurse ask the client to assess the progressive nature of symptoms of the disease to the next stage?

"Are you able to perform your ADL independently?" As the client is already in the state of moderate cognitive decline, which is characterized by the increasing inability of the client to perform ADLs, asking this question will help the nurse evaluate disease progression.

A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern?

"Do you feel afraid that people are trying to hurt you?"

The registered nurse is teaching students about the care plan provided to a client with hallucinations. Which statement made by the student nurse needs correction?

"Encourage reflection on the client's life." Encouraging the client's review of the past may create a disturbance in the client. Rumination should be discouraged. Therefore, this statement made by the student nurse needs correction.

While communicating with a client who has a delayed ability to process verbal communications, the nurse finds that the client is unable to understand the question. How would the nurse respond to this client?

"I will rephrase the question for you." If the client is unable to understand the question, the nurse should rephrase the question in an easy way to help the client understand it.

A widowed client is diagnosed with neurocognitive disorder (NCD) due to Alzheimer's disease (AD). On interaction, the client says, "It's my birthday today. I am going out with my husband." Which response by the nurse is most appropriate in this situation?

"Tell me about your husband. What was it like when you were together?" A client with NCD due to AD should be encouraged by asking questions that recall good memories. This helps increase the client's self-esteem and improve mood.

A client with neurocognitive disorder (NCD) diagnosed with a disturbed thought process is undergoing psychotherapy. Which outcome does the nurse expect in the client on reassessment?

"The client experiences fewer episodes of confusion." A client with NCD diagnosed with a disturbed thought process experiences fewer episodes of confusion when receiving treatment.

A client who is in stage 4 of Alzheimer's disease (AD) is undergoing psychotherapy. Which statement made by the client's caregiver indicates effective treatment?

"The client is able to understand and accept problems." A client who is in stage 4 of AD may experience confabulation, in which the client creates imaginary events to fill in memory gaps and denies the existence of a problem. As the client is able to understand and accept problems, it indicates that the treatment is effective.

The night nurse finds a client with Alzheimer's disease wandering the hallway at 4 a.m. and trying to open the door to the side yard. Which of the following is the best initial response by the nurse?

"This is the patio door. Are you looking for the bathroom?"

A client, who has neurocognitive disorder due to Alzheimer's disease, says to the nurse, "I have a date tonight. I always have a date on Christmas." Which of the following is the most appropriate response?

"Today is Tuesday, October 21, Mrs. G. We will have supper soon, and then your daughter will come to visit."

Which instructions does the nurse provide to the spouse of a client suffering from severe cognitive decline? Select all that apply.

"Your spouse may not be able to recognize some family members." A client w/ severe cognitive decline frequently has difficulty recognizing family members. "Your spouse may be more aggressive during late afternoons & evenings." Aggressive behavior is evident in a client w/ severe cognitive decline, and it will peak during late afternoons and evenings. This is called sundowning. "It is more important to provide institutional care for your spouse." Institutional care is usually required for clients w/ severe cognitive decline b/c the client is bed bound and unable to perform ADLs. "Watch out for infections like pneumonia in your spouse caused by decreased immunity." Risk for infections like pneumonia increases in clients w/ severe cognitive decline d/t decreased immunity and the rigid nature of muscles.

During the mental status examination for neurocognitive disorder (NCD), the client is only able to say the date and day of the week correctly. Which number would the nurse assign for the orientation score of the client? Record your answer as a whole number. Enter numeral only.

4 The score assigned for correct date is 2 points, and the score for the correct day of the week is two points. Therefore, the total score of the client for orientation is four points.

While assessing the verbal fluency of a client, the nurse finds that the client names 10 animals in a time span of 60 seconds. Which score does the nurse record in the client's medical record? Record your answer as a whole number. Enter numeral only.

5 The client's score for verbal fluency is assigned as one point for every two animals. In this case, the client verbalized the names of 10 animals in 60 seconds. Therefore, the client's score is 10 / 2 = 5 points.

For which client is it most important to have electronically controlled exit doors in a health-care facility?

A client with wandering behavior Electronically controlled exit doors will prevent a client with wandering behavior from leaving the health-care facility, thereby keeping the client safe. Therefore, the client with wandering behavior is at less risk for injuries.

A client is admitted to the mental health unit w/ a diagnosis of depression. The nurse should develop a plan of care for the client that includes which of the following?

A structured program of activities in which the client can participate.

Which nursing intervention is beneficial for a client who has disturbed thought processes?

Initiating reminiscence therapy Reminiscence therapy will help the client share happy moments of his or her life. This helps decrease depression and boost self-esteem in a client who is depressed due to disturbed thought processes.

Which psychomotor symptoms are observed in a client who is in the severe cognitive decline stage of Alzheimer's disease (AD)? Select all that apply.

Aggression Aggression is one of the psychomotor symptoms in a client who is in the severe decline stage of AD. Wandering Wandering is one of the psychomotor symptoms in a client who is in the severe decline stage of AD. Obsessiveness Obsessiveness is one of the psychomotor symptoms in a client who is in the severe decline stage of AD.

The client's medical history indicates that his or her delirium is caused by substance withdrawal. Which class of medications does the primary health-care provider prescribe to the client in this situation?

Antianxiety Antianxiety agents, such as benzodiazepines, are the treatment of choice in a client with delirium when the etiology is substance withdrawal.

The nurse is caring for a client with cardiopulmonary disorder who recently had a head injury. On interaction, the nurse finds that the client has a misperception of the environment and likely has delirium. Which medication, along with the head trauma, does the nurse expect to be the cause of this condition in the client?

Antihypertensive agents Certain medications may precipitate delirium. Antihypertensive agents cause medication-induced delirium.

Which of the following interventions is most appropriate in helping a client with Alzheimer's disease with ADLs? (Select all that apply.)

Assist her with step-by-step instructions. Encourage her and give her plenty of time to perform independently as many of her ADLs as possible.

A client with neurocognitive disorder (NCD) is diagnosed with risk for trauma. Which nursing interventions require correction while caring for this client? Select all that apply.

Avoiding night lights in the client's room The client may experience disorientation during night. Therefore, dim night lights should be used in the client's room. This nursing intervention requires correction. Storing frequently used items out of the client's reach The nurse should store frequently used items within easy access. Therefore, this nursing intervention requires correction. Keeping bedrails down when the client is in the bed The nurse should keep the bedrails up when the client is in bed to prevent the risk of falls and injuries. Therefore, this nursing intervention requires correction.

Which medications are beneficial to a client with neurocognitive disorder (NCD) experiencing apathy? Select all that apply.

Bupropion Bupropion is a dopaminergic agent that may be helpful in a client with apathy. Amantadine Amantadine is a dopaminergic agent that may be helpful in a client with apathy. Methylphenidate Methylphenidate is a dopaminergic agent that may be helpful in a client with apathy.

Which conditions are known to cause secondary neurocognitive disorders (NCDs) in a client? Select all that apply.

Cerebral trauma Cerebral trauma is an intracranial injury. It is one of the causes of secondary NCDs. HIV disease HIV is one of the causes of secondary NCDs.

A client with Alzheimer's disease may make up events to fill in memory gaps. What is this condition called?

Confabulation Confabulation is a condition in which the client creates events to fill in memory gaps.

Which exogenous factors are implicated in the development of delirium in a client? Select all that apply.

Contusions Contusions refer to bruises after trauma. Contusions are one of the exogenous factors implicated in the development of delirium. Prolonged labor Prolonged labor is one of the exogenous factors implicated in the development of delirium. Obstetric complications Obstetric complication is one of the exogenous factors implicated in the development of delirium.

Which of the following medications has been indicated for improvement in cognitive functioning in mild to moderate Alzheimer's disease? (Select all that apply.)

Donepezil (Aricept) Rivastigmine (Exelon) Galantamine (Razadyne)

The spouse of a boxer says, "My partner is having difficulty speaking." On assessment, the nurse also finds that the client has difficulty picking up objects. Which condition does the nurse suspect in the client?

Dementia pugilistica Dementia pugilistica is a condition experienced by boxers in which there is emotional liability, dysarthria (difficulty in speech), ataxia (difficulty in picking up objects), and impulsivity.

A client is admitted into the psychiatric unit with the complaint of pressured and incoherent speech. On further interaction, the nurse finds that the client is suffering from delirium. Which nursing intervention is the priority in this situation?

Determine and correct the underlying causes. The priority nursing intervention is to determine and correct the underlying causes of delirium. To plan treatment, it is essential to know the factors responsible for the delirium.

A client with Parkinson's disease has involuntary muscle movements and rigidity. What is the pathophysiology associated with these symptoms?

Diminished dopamine activity In a client with Parkinson's disease, the activity of the neurotransmitter dopamine is diminished, resulting in involuntary muscle movements, slowness, and rigidity.

Which medication is useful in treating moderately severe cognitive impairment in a client with a neurocognitive disorder (NCD)?

Donepezil Donepezil is a cholinesterase inhibitor used to treat mild-to-moderate to severe cognitive impairment in a client with an NCD.

An example of a treatable (reversible) form of NCD is one that is caused by which of the following? (Select all that apply.)

Electrolyte imbalance Folate deficiency

Which characteristics does the nurse observe in a client with dementia pugilistica? Select all that apply.

Emotional liability A client with dementia pugilistica avoids confronting feelings. Therefore, the nurse observes emotional liability in the client. Dysarthria Dementia pugilistica is caused by traumatic head injury, which may impair the speech of a client due to brain atrophy. Therefore, the nurse observes motor speech disorder, or dysarthria, in the client. Ataxia Dementia pugilistica is caused by traumatic head injury, which may affect the voluntary coordination of muscle movement due to brain atrophy. Therefore, the nurse observes a lack of voluntary coordination of muscle movement, or ataxia, in the client.

A client who has NCD due to Alzheimer's disease has trouble sleeping and wanders around at night. Which of the following nursing actions would be best to promote sleep in this client?

Ensure that the client gets regular physical exercise during the day.

A client with neurocognitive disease due to Alzheimer's disease is admitted to the hospital. Which of the following actions by the nurse is a priority?

Ensuring that the environment is safe to prevent injury

Which conditions are known to precipitate delirium in a client? Select all that apply.

Febrile illness Delirium is a disturbance in awareness and attention and a change in cognition. Febrile illness can precipitate delirium in a client. Systemic infections Systemic infections can precipitate delirium in a client. Hepatic encephalopathy Hepatic encephalopathy can precipitate delirium in a client.

Which condition does the nurse suspect in the client with neurocognitive disorder (NCD) who has increased difficulty understanding spoken language?

Frontotemporal NCD Rationale: Frontotemporal NCD is characterized by an increasing difficulty understanding written or spoken language. Therefore, the client is suspected of having frontotemporal NCD.

Which factor is most significant in the etiology of multiple strokes in a client with vascular neurocognitive disorder (NCD)?

Hypertension Hypertension is one of the most significant factors in the etiology of multiple strokes in a client with vascular NCD.

The nurse is teaching a group of student nurses about the metabolic disorders that precipitate delirium or neurocognitive disorder (NCD) in a client. Which conditions does the nurse include in the teaching plan? Select all that apply.

Hypoxia Hypoxia is the decrease in oxygen levels in the blood. Lack of oxygen results in degeneration of neural tissues and precipitates delirium or NCD in the client. Hypercarbia Increase in carbon dioxide levels in the blood may decrease the supply of oxygen to the brain and result in delirium or NCD in the client. Hypoglycemia Decreased blood glucose levels affect the functioning of the central nervous system and may precipitate delirium or NCD in the client.

Which statement describes the possible etiology for neurocognitive decline in a client who had a recent fracture of a femur bone?

Interruption of blood flow Fracture of a femur, which is a long bone, will release fat that will form emboli in the blood vessels in the brain. This interrupts the blood flow in the brain and results in neurocognitive decline.

Which intervention would the nurse implement while caring for a client with neurocognitive disorder (NCD) and diagnosed with wandering behavior?

Keeping the client on a structured schedule of recreational activities A client with NCD shows wandering behavior due to confusion. Therefore, keeping the client on a structured schedule of recreational activities will help minimize confusion and reduce wandering behavior.

Which nursing intervention is effective in an agitated client who is at risk for trauma?

Maintaining a low level of stimuli in the environment In an agitated client who is at risk for trauma, maintaining low-level stimuli is an effective intervention.

A client with neurocognitive decline is diagnosed with neuronal degradation caused by overstimulation of the N-methyl-D-aspartate (NMDA) receptors. Which medication does the nurse expect the primary health-care provider to prescribe?

Memantine Memantine, as an NMDA receptor antagonist, blocks NMDA receptors and decreases intracellular calcium. This results in reduced neuronal degradation.

Which behavioral sign does the nurse find in a client diagnosed with mild neurocognitive disorder (NCD)?

Modest cognitive decline in learning and memory A client with mild NCD will show modest cognitive decline in learning and memory because the disorder is in the initial stages.

Which of the following factors is not associated with an increased incidence of neurocognitive disorder due to Alzheimer's disease?

Multiple small strokes

The nurse is teaching a group of student nurses about various forms of neurocognitive disorders (NCDs). Which disorders does the nurse refer to as being reversible? Select all that apply.

NCD due to folate deficiency NCD due to folate deficiency is reversible. The abnormal folate levels in the body may be brought to the normal level with the help of supplements or balanced nutrition. NCD due to side effects of medications NCD due to side effects of medications is reversible. It can be treated either by discontinuing the drug concerned or with the help of other medications. NCD due to central nervous system infections NCD due to central nervous system infections is reversible. It can be treated with the help of medications prescribed based on the type of infection.

Which medication does the nurse expect the primary health-care provider to prescribe for a client with neurocognitive disorder (NCD) who is agitated and aggressive?

Olanzapine Olanzapine is an atypical antipsychotic that is preferred to treat agitation and aggression in a client with NCD.

The nurse asks a client with neurocognitive disorder (NCD) about today's date. Which behavior of the client is the nurse assessing?

Orientation Asking the client about today's date would help assess the client's orientation to reality.

Which medications are preferred for a client with neurocognitive disorder (NCD) experiencing anxiety? Select all that apply.

Oxazepam Drugs with shorter half-lives are preferable to drugs with longer half-lives in a client with anxiety. Oxazepam is a drug with a shorter half-life. Thus, it is preferred. Lorazepam Lorazepam is a drug with a shorter half-life. Thus, it is preferred for a client with NCD experiencing anxiety.

An elderly client with neurocognitive disorder (NCD) is found to be anxious. Which medications help reduce the client's anxiety? Select all that apply.

Oxazepam Oxazepam is a benzodiazepine with a short half-life. Therefore, this medication is beneficial to the client because it does not promote the risk of oversedation and falls. Lorazepam Lorazepam is a benzodiazepine with a short half-life. Therefore, this drug is beneficial to the client because it prevents the risk of oversedation and falls.

In addition to disturbances in cognition and orientation, individuals with Alzheimer's disease may also show changes in which of the following? (Select all that apply.)

Personality Speech Mobility

Which action does the nurse implement to prevent the risk of accidental trauma while caring for a client with neurocognitive disorder (NCD)?

Positioning the bed as low as possible Positioning the bed as low as possible for a client with NCD will help prevent trauma if the client falls from the bed due to seizures or tremors.

The nurse is caring for a client who has impaired ability to perform his or her own activities. Which nursing intervention may minimize the client's confusion?

Providing consistency in the assignment of daily caregivers Providing consistency in the assignment of daily caregivers is an effective intervention in a client with self-care deficits, which may help minimize confusion.

The client's spouse says, "My partner is depressed in the morning and is fine in the evening." What does the nurse suspect in the client?

Pseudodementia Pseudodementia, also called depression, is a condition that mimics a neurocognitive disorder. In this condition, the symptoms are worse in the morning and are better as the day progresses.

Which medication is used in the treatment of agitation?

Risperidone Risperidone is an antipsychotic drug used in the treatment of psychotic symptoms such as agitation.

Which medication prescribed for agitation is known to cause extrapyramidal symptoms?

Risperidone Risperidone is known to cause agitation, insomnia, headache, and extrapyramidal symptoms.

What first-line drug treatment would the nurse expect to be prescribed for an elderly client diagnosed with neurocognitive depression?

Sertraline Sertraline is a selective serotonin reuptake inhibitor, which is considered a first-line drug treatment in an elderly client with neurocognitive depression.

Which stage of Alzheimer's disease (AD) is characterized by sundowning?

Severe cognitive decline In severe cognitive decline, symptoms worsen in the late afternoon and evening. This phenomenon is known as sundowning.

Which focal neurological signs are commonly observed in a client with vascular neurocognitive disorder (NCD)? Select all that apply.

Small-stepped gait Small-stepped gait is a focal neurological sign in a client with NCD. Difficulty with speech Difficulty with speech is a focal neurological sign in a client with NCD. Weakness of the limbs Weakness of the limbs is a focal neurological sign in a client with NCD.

After assessing a client's behaviors, the nurse concludes that the client is in stage 4 of Alzheimer's disease (AD). Which behavior of the client supports the nurse's conclusion?

The client denies the existence of the problems by covering up memory loss. In stage 4 of AD, the client has moderate cognitive decline. The client denies the existence of the problems by covering up memory loss.

After assessing the cognitive capacity of a client with Alzheimer's disease (AD), the nurse concludes that the client is in the fourth stage of the disease. Which finding supports the nurse's conclusion?

The client is unable to understand current news events. The client with AD who is in the fourth stage of the disease has moderate cognitive decline. The client cannot understand current news events during this stage of illness. This finding supports the nurse's conclusion.

While caring for a client who is at risk for trauma, the nurse maintains a low level of stimuli in the environment. Which outcome in the client indicates the effectiveness of treatment?

The client will maintain a calm demeanor with minimal agitated behavior. The nurse should maintain a low level of stimuli in the environment. This intervention is applicable for an agitated client who is at risk for trauma and helps the client maintain a calm demeanor with minimal agitated behavior.

While caring for a cognitively impaired client, the nurse provides a cane and instructs the client about its use. Which outcome will the nurse expect from this intervention?

The client will not experience physical injury. A cognitively impaired client will also have impairment in psychomotor function and be unable to perform motor activities. Providing a cane and instructing the client about its proper use will help the client walk and prevent physical injury.

The nurse is providing soft restraints to a client who is at risk for trauma. Which outcome in the client would indicate the effectiveness of the nursing intervention?

The client will not experience physical injury. Soft restraints are provided to a client who is disoriented and hyperactive. Providing soft restraints will help the client avoid physical injury.

The nurse is caring for a client with self-care deficits. Which outcome will demonstrate the effectiveness of the nursing intervention?

The client will participate in the activities of daily life with the assistance of caregivers. Participating in daily life activities with the assistance of caregivers is an effective outcome. This outcome demonstrates the effectiveness of nursing intervention in a client with self-care deficits.

Which statement describes the long-term goal for the client with an impaired ability to process verbal communication?

To increase the client's ability to express his or her needs so they are easily anticipated and fulfilled by caregivers The long-term goal for a client with impaired verbal communication is to increase the client's ability to express his or her needs so they are easily anticipated and fulfilled by caregivers.

Which symptoms does the nurse observe in a 34-year-old client diagnosed with neurocognitive disorder (NCD) due to Huntington's disease? Select all that apply.

Twitching of limbs In a client with Huntington's disease, the neurons of the basal ganglia and the cerebral cortex are damaged. This results in involuntary movement of the limbs and facial muscles. Emotional impairment Emotional impairment is observed in clients with Huntington's disease due to damage in the cerebral cortex. Short-term memory loss Damage to the basal ganglia and cerebral cortex in Huntington's disease will result in mild cognitive changes that involve short-term memory loss.

A client has been diagnosed with NCD due to Alzheimer's disease. The cause of this disorder is which of the following?

Unknown

A client diagnosed with delirium becomes disorientated and confused at night. Which intervention should the nurse implement initially>?

Use an indirect light source and turn off the television.

An elderly client with neurocognitive disorder (NCD) is experiencing anxiety and has a medical history of confusion and paradoxical excitement. Which statement describes the possible reason for the occurrence of these symptoms in the client?

Use of barbiturates Barbiturates are contraindicated in elderly clients. They produce confusion and paradoxical excitement in clients with NCD experiencing anxiety.

The nurse is caring for a client with disorientation and confusion. Which nursing interventions are helpful for providing orientation to reality for the client? Select all that apply.

Using reminiscence therapy Reminiscence therapy involves recalling past events of the client's life. Using reminiscence therapy is an excellent way to provide orientation to reality. Allowing the client to view old photographs Allowing the client to view old photographs is an excellent way to provide orientation to reality.

The blood pressure of a client with a psychiatric illness is found to be 180/100 mm Hg. The brain scan report reveals the presence of cerebral infarcts. Which complication does the nurse suspect in the client based on these findings?

Vascular neurocognitive disorder (NCD) Hypertension causes damage to the lining of blood vessels. Cerebral infarcts interrupt the blood flow to the brain. Therefore, the nurse suspects vascular NCD in the client.

The nurse is reviewing laboratory values for a client with delirium. Which deficiency would play a role in the development of delirium?

Vitamin B Rationale: Vitamin B deficiency may lead to the development of delirium. Remediation of this deficiency may potentially correct the underlying cause of the confusion.