N127 - HESI
What does the nurse suspect that the client is experiencing? a. Delirium. b. Dementia. c. Schizophrenia. d. Delirium tremens.
a. Delirium. Rationale: Recent onset along with visual hallucinations indicates a possible delirium. ___Wrong Answers___ b. Dementia - Dementia has a slow onset. c. Schizophrenia - Initial symptoms are usually seen in young adulthood. d. Delirium tremens (rapid onset of alcohol withdrawn) - The client does not have a history of substance abuse and his vital signs do not indicate delirium tremens.
Which question gives the nurse the most information about the client's judgment? a. "Are you in good spirits most of the time?" b. "If you smelled smoke in a movie theater, what would you do?" c. "Who is the current President of the United States?" d. "What was the name of your favorite childhood pet"
b. "If you smelled smoke in a movie theater, what would you do?" Rationale: This question elicits the most information about judgment. The client must know what a fire is and describe how he would react. ___Wrong Answers___ a. "Are you in good spirits most of the time?" - This question is part of a geriatric depression assessment scale and does not adequately assess judgment. c. "Who is the current President of the United States?" - This question elicits information about short-term memory and does not adequately assess judgment. d. "What was the name of your favorite childhood pet" - This question elicits information about long-term memory and does not adequately assess judgment. Submit
What is the nurse's best response? a. Tell the daughter that her father is in the middle stage of this disease and he will stabilize at this level of functioning for some time. b. Explain that everyone responds differently to this disease, but it is likely that his health and daily functioning will continue to decline. c. Let the daughter know that it is evident that she is worried about her father, but there is nothing that you can do. d. Ask the daughter if she has a friend or a family member who can help her.
b. Explain that everyone responds differently to this disease, but it is likely that his health and daily functioning will continue to decline. Rationale: This is the most accurate description of this disease, and it allows the client's daughter to participate in her father's plan of care. ___Wrong Answers___ a. Tell the daughter that her father is in the middle stage of this disease and he will stabilize at this level of functioning for some time. The nurse does not know the course of this illness for this client. c. Let the daughter know that it is evident that she is worried about her father, but there is nothing that you can do. This statement is not accurate and it may make the client's daughter feel hopeless and helpless when she needs support. d. Ask the daughter if she has a friend or a family member who can help her. This is avoiding the question, and it does not give the information that the client's daughter needs to plan for the future.
Which laboratory test should be scheduled? a. Serum BUN and creatinine. b. Serum liver enzymes. c. Urinalysis. d. White blood count.
b. Serum liver enzymes. Rationale: Liver toxicity is a significant side effect of acetylcholinesterase inhibitors, so liver function tests should be monitored regularly. ___Wrong Answers___ a. Serum BUN and creatinine. **Renal function is not significantly affected by acetylcholinesterase inhibitors. c. Urinalysis. **Donepezil may cause nocturia (voiding 1 or 2 time at night time) or urinary incontinence, but urine will not be affected by the medication. d. White blood count. **Infection and immunosuppression are not significant side effects of acetylcholinesterase inhibitors.
"During the assessment, the client becomes anxious, states that his memory is fine and asks why he is being asked all these questions." What is the best response by the nurse to address the client? a. Tell the client to hang in there and the assessment will be done soon. b. Have the client take a break and offer him a cup of water. c. Let the client know that his cooperation is appreciated and have the client say what he think is the problem. d. Remind the client how worried his daughter is about him. Submit
c. Let the client know that his cooperation is appreciated and have the client say what he think is the problem. Rationale: This acknowledges the client's concerns and engages him in his own care as much as possible. Giving the client some control may decrease his anxiety. ___Wrong Answers___ a. Tell the client to hang in there and the assessment will be done soon - This does not address the client's concerns, and using jargon is not appropriate. b. Have the client take a break and offer him a cup of water - This does not address the client's concerns. d. Remind the client how worried his daughter is about him - This may be true, but it does not address the client's feelings.
What is the goal of nursing care for a client with a neurocognitive disorder due to Alzheimer's disease? a. Individualizing care. b. Improving cognition. c. Maintaining optimum function. d. Promoting self-confidence and self-esteem.
c. Maintaining optimum function. Rationale: There is not a cure for Alzheimer's disease, but support can help the client and the client's family live at a maximum functional level. ___Wrong Answers___ a. Individualizing care - This is the approach, not the desired outcome. b. Improving cognition - Chronic illness with a slow decline. d. Promoting self-confidence and self-esteem - This is the approach, not the desired outcome.
"The client's daughter cares for her father in their home with the help of the home healthcare team until his Alzheimer's disease progresses to the point where the client is completely bedridden and is no longer able to perform any self-care measures. The client's daughter notifies the nurse that she plans to place her father in a long-term care facility. While speaking with the nurse, the daughter states that she thinks her dad would be better off dead and she feels so guilty for even thinking that." What is the best response by the nurse? a. Empathize with the daughter and agree that they would feel guilty for thinking that, too. b. Ask the daughter why she feels her father would be better off. c. Suggest that the daughter is just too tired to think clearly. d. Acknowledge that the daughter has many conflicting emotions right now.
d. Acknowledge that the daughter has many conflicting emotions right now. Rationale: This response restates the daughter's feelings and provides the opportunity for her to continue to share concerns. ___Wrong Answers___ a. Empathize with the daughter and agree that they would feel guilty for thinking that, too. **This response is judgmental and blocks further communication. b. Ask the daughter why she feels her father would be better off. **The use of "why" is often perceived as challenging, and it should not be used by the nurse when seeking to maintain therapeutic communication. c. Suggest that the daughter is just too tired to think clearly. **This response trivializes her feelings and blocks further communication.
Section 15: "The nurse obtains the following assessment data: Temperature 96.8°F (35.5°C), Heart Rate 100 beats/min, Respirations 24 breaths/min, Blood Pressure 70/44, Oxygen Saturation 96%." After assisting the client to the bed, which nursing action has the highest priority? a. Administer oxygen per nasal cannula. b. Notify the HCP of the vital signs. c. Provide several warm blankets. d. Elevate the client's feet fifteen degrees.
d. Elevate the client's feet fifteen degrees. Rationale: The client is experiencing hypotension secondary to his initial dose of the antipsychotic medication. The priority nursing action is to restore his blood pressure. ___Wrong Answers___ a. Administer oxygen per nasal cannula. **The client's O2 saturation is within normal limits (WNL); therefore, administration of oxygen is not warranted. b. Notify the HCP of the vital signs. **Immediate action should be taken before contacting the HCP. c. Provide several warm blankets. **This is an important intervention since the client's temperature is low, but it is not the highest priority. A temperature below 96.8°F (35.5°C) is considered hypothermia.
Which are common components of an advance directive for healthcare? (Select all that apply. One, some, or all options may be correct Select all that apply 1. Appointment of another person to make healthcare decisions if the client is unable. 2. Specific or general instructions about physical healthcare treatment. 3. The naming of individuals to whom personal possessions will be given in the event of a death. 4. Specific or general instructions about mental or psychological healthcare treatment. 5. A section explaining the document is legal and cannot be changed by the client once signed.
1. Appointment of another person to make healthcare decisions if the client is unable. **Decisions or preferences about physical healthcare treatment such as the use or nonuse of a ventilator can be outlined in an advance directive for healthcare. 2. Specific or general instructions about physical healthcare treatment. **Decisions or preferences about mental or psychological healthcare treatment such as the use or nonuse of electrical shock treatment can be outlined in an advance directive for healthcare. 4. Specific or general instructions about mental or psychological healthcare treatment. **Decisions or preferences about mental or psychological healthcare treatment such as the use or nonuse of electrical shock treatment can be outlined in an advance directive for healthcare. ___Wrong Answers___ 3. The naming of individuals to whom personal possessions will be given in the event of a death. **This is not a component of an advance directive for healthcare. 5. A section explaining the document is legal and cannot be changed by the client once signed. **An individual may change their advance directive for healthcare if the individual has the mental capacity to do so and is acting freely without pressure from another person or agency.
Which of the following are risk factors for Alzheimer's Disease: (Select all that apply. One, some, or all options may be correct.) Select all that apply 1. Genetic predisposition. 2. History of head trauma. 3. Male gender. 4. High cholesterol levels. 5. Cooking with teflon coated pans.
1. Genetic predisposition - Genetic predisposition increases risk by 60-70 %. 2. History of head trauma - Brain injury is associated with a greater risk. 4. High cholesterol levels - Lifestyles associated with cardiovascular disease such as high cholesterol, diabetes, and obesity increase the risk. ___Wrong Answers___ 3. Male gender - Alzheimer's disease may affect women more post menopause. 5. Cooking with teflon coated pans - There is no documented evidence that teflon causes Alzheimer's disease. Submit
Which behaviors are commonly associated with caregiver role strain? (Select all that apply) One, some, or all options may be correct. Select all that apply: 1. Reports of physical symptoms such as frequent headaches. 2. Feels a sadness that will not go away. 3. Allows other family members to provide care one day per week. 4. Frequently forgets to change care recipient's soiled linens. 5. Withdraws from family and friends. Submit
1. Reports of physical symptoms such as frequent headaches. **Reports of frequent physical symptoms are a sign of caregiver stress. 2. Feels a sadness that will not go away. **Mental health issues, including depression, are prevalent among caregivers of clients with chronic illnesses such as Alzheimer's disease. 4. Frequently forgets to change care recipient's soiled linens. **Abuse or neglect is sometimes associated with increased caregiver stress or burden. 5. Withdraws from family and friends. **Caregivers who are experiencing stress often withdraw from family, friends, and social activities. ___Wrong Answers___ 3. Allows other family members to provide care one day per week. **Allowing other family members to provide care is a therapeutic response to caregiving and does not indicate increased stress or burden.
Which of the following memory issues/deficits are related to Mild Neurocognitive Disorder due to Alzheimer's disease? (Select all that apply. One, some, or all options may be correct. Select all that apply 1. Temporarily misplaced keys and purse. 2. Forgets the purpose or use of an item. 3. Cooks a meal and forgets to serve it. 4. Momentarily forgets an acquaintance's name. 5. Becomes lost on the client's own street.
2. Forgets the purpose or use of an item - This type of memory loss is associated with mild Alzheimer's disease. 5. Becomes lost on the client's own street - This type of memory loss is associated with mild Alzheimer's disease. They have trouble with planning or organizing. ___Wrong Answers___ 1. Temporarily misplaced keys and purse - The temporary misplacement of items is typically associated with "normal forgetfulness." Key word is temporary. Momentarily forgets an acquaintance's name - Occasional or momentary lapse in memory is typically associated with "normal forgetfulness." Becomes lost on the client's own street - This type of memory loss is associated with moderate Alzheimer's disease.
What should the nurse advise the client's daughter to do? (Select all that apply. One, some, or all options may be correct.) Select all that apply 1. Ignore the behavior. 2. Tell her father that the man is a friend. 3. Make sure her father's room has sufficient light. 4. Tell her father that he does not see anyone and that it is in his imagination. 5. Divert her father's attention with food or drink.
3. Make sure her father's room has sufficient light - Shadows can increase confusion and support delusions. 5. Divert her father's attention with food or drink - Night time confusion can be reduced by diverting the client to something familiar and soothing. ___Wrong Answers___ 1. Ignore the behavior. The client is anxious and needs assistance. 2. Tell her father that the man is a friend. A false reality should not be supported. 4. Tell her father that he does not see anyone and that it is in his imagination. Dismissing the client's experience will not lower his anxiety.
How does donepezil reduce the symptoms for clients with mild to moderate Alzheimer's disease? a. Enhancing acetylcholine function. b. Inhibiting serotonin uptake. c. Anti-oxidating free radical. d. Reducing GABA action.
a. Enhancing acetylcholine function. Rationale: Donepezil prevents an enzyme known as acetylcholinesterase from breaking down acetylcholine in the brain. Increased concentrations of acetylcholine lead to increased communication between the nerve cells that use acetylcholine as a chemical messenger, which may temporarily improve or stabilize the symptoms of Alzheimer's disease. ___Wrong Answers___ b. Inhibiting serotonin uptake. **This is not the mechanism of action for donepezil. c. Anti-oxidating free radical. **This is not the mechanism of action for donepezil. d. Reducing GABA action. **This is not the mechanism of action for donepezil.
"Two hours after the oxazepam is administered, the nurse notes that the client is sitting quietly in a chair and he finally seems ready to settle down for the night. However, when the client attempts to stand, he is weak, drowsy, and diaphoretic." What initial action should the nurse take? a. Evaluate the client's vital signs before transferring him to his bed. b. Monitor the client's blood glucose level after he is back in his bed. c. Assist with transferring the client to his bed and turn on a night light. d. Advise the UAP to turn off the room light and let the client rest in the chair.
a. Evaluate the client's vital signs before transferring him to his bed. Rationale: The client may be experiencing an adverse effect of the medication, and he should be assessed before further action is initiated. ___Wrong Answers___ b. Monitor the client's blood glucose level after he is back in his bed. **There is no reason to anticipate a change in his blood glucose level. c. Assist with transferring the client to his bed and turn on a night light. **The client is exhibiting signs of a physiological problem. Nursing assessment is warranted. d. Advise the UAP to turn off the room light and let the client rest in the chair. **He is exhibiting signs of a physiological problem. Nursing assessment is warranted.
What action should the nurse implement first? a. Redirect the client's attention to a familiar object from his home. b. Quietly leave the room until he calms down. c. Assign a UAP to remain with the client. d. Apply a soft vest restraint and bed alarm.
a. Redirect the client's attention to a familiar object from his home. Rationale: The nurse should first attempt to calm the client by redirecting his attention or distracting him from the source of the anxiety. ___Wrong Answers___ b. Quietly leave the room until he calms down. **Although it may be useful to leave the room if the client is not likely to harm himself, this is not the first action that the nurse should implement. c. Assign a UAP to remain with the client. **This may be useful, but it is not the first action that the nurse should implement. d. Apply a soft vest restraint and bed alarm. **From an ethical-legal perspective, the use of a physical restraint is always the last choice, and it should be considered only if all other interventions fail to ensure client safety.
Which side effect of donepezil is most important for the client's daughter to report to the HCP? a. Tarry stool. b. Fatigue. c. Loss of appetite. d. Insomnia.
a. Tarry stool. Rationale: A bloody, black or tarry stool may indicate GI bleeding, a serious side effect of the medication. ___Wrong Answers___ b. Fatigue. **Fatigue is a common side effect of donepezil, but it is not the most critical side effect. c. Loss of appetite. **Loss of appetite is concerning, but this is not the most critical side effect. d. Insomnia. **Insomnia is a common side effect of donepezil, but it is not the most critical side effect. Submit Previous Section
What is the best initial response by the nurse? a. Tell the daughter that changes in behavior and personality often occur as Alzheimer's disease progresses. b. Explain to the daughter that behavior changes may indicate that he has already progressed to a later stage of the disease. c. Assure the daughter that behavior changes are probably the result of his effort to cope with his altered mental function. d. Help the daughter understand that behavior changes usually indicate that the person is feeling depressed about the situation. Submit Previous Section
a. Tell the daughter that changes in behavior and personality often occur as Alzheimer's disease progresses. Rationale: Subtle changes in behavior and personality, which would easily be recognized by a loved one, occur even in early Alzheimer's disease. __Wrong Answers___ b. Explain to the daughter that behavior changes may indicate that he has already progressed to a later stage of the disease - These changes do not occur only at a late stage of Alzheimer's disease. c. Assure the daughter that behavior changes are probably the result of his effort to cope with his altered mental function - Although this may be a contributing factor, it is not the most accurate information about behavioral changes in Alzheimer's disease. d. Help the daughter understand that behavior changes usually indicate that the person is feeling depressed about the situation - Although this may be a contributing factor, it is not the most accurate information about behavioral changes in Alzheimer's disease. Submit Previous Section
Which information would support the daughter's statement about trazodone? a. The client sleeps through the night. b. The client is able to control his bladder at times. c. The client wanders around the house. d. The client denies feeling any pain.
a. The client sleeps through the night. Rationale: Trazodone is an antidepressant often used to improve sleep in the client with Alzheimer's disease. ___Wrong Answers___ b. The client is able to control his bladder at times. **Trazodone has no effect on bladder control. c. The client wanders around the house. **Wandering behavior is not an indication of stabilized cognitive functioning. d. The client denies feeling any pain. **Trazodone is not an analgesic.
"Since the client will be taking donepezil, the nurse schedules him for laboratory tests in 6 months as prescribed by the HCP." What is the goal for the care of a client with mild-to-moderate Alzheimer's disease who takes donepezil? a. The client will maintain the highest level of cognitive ability. b. The client will demonstrate improved cognitive ability within one month. c. The client will engage in abstract thinking within one month. d. The client will communicate clearly within one month.
a. The client will maintain the highest level of cognitive ability. Rationale: Donepezil slows cell destruction. ___Wrong Answers___ b. The client will demonstrate improved cognitive ability within one month. **Donepezil only slows cell destruction. c. The client will engage in abstract thinking within one month. **Due to cell destruction of executive functioning, this is not possible. d. The client will communicate clearly within one month. **While taking donepezil, the client will maintain communication patterns for limited periods; however, the medication will not improve the client's disease process.
What is the best response by the nurse? a. Insist that the daughter correct the client's inaccurate statements to promote reality orientation. b. Encourage the daughter and let her know that she is right to balance the client's feelings with the need to promote reality. c. Tell the daughter that her dad is attempting to manipulate her and make sure he gets his own way. d. Say to the daughter that there is no reason to attempt to correct her father because he will not understand.
b. Encourage the daughter and let her know that she is right to balance the client's feelings with the need to promote reality. Rationale: Reality orientation is an important tool for the client with Alzheimer's disease, unfortunately, as the disease progresses, it often causes the client to become agitated. It is important to recognize the feelings and emotions of the client with Alzheimer's disease. ___Wrong Answers___ a. Insist that the daughter correct the client's inaccurate statements to promote reality orientation. **Reality orientation is an important tool for the client with Alzheimer's disease, but it is also important to recognize and respect the client's feelings. c. Tell the daughter that her dad is attempting to manipulate her and make sure he gets his own way. **This statement is judgmental and uncaring. d. Say to the daughter that there is no reason to attempt to correct her father because he will not understand. **Reality orientation is an important tool for the client with mild to moderate Alzheimer's disease, and it should be included in the client's care whenever possible.
Which response by the nurse is most therapeutic? a. Tell the daughter that this may be traumatic so it is best for her to wait outside the room. b. Have the daughter pull up a chair so that she may sit on the left side of the bed and hold her dad's hand. c. Ask the client if he wants the daughter to stay in the room for the procedure. d. Explain how clients generally follow staff requests if family members are not present.
b. Have the daughter pull up a chair so that she may sit on the left side of the bed and hold her dad's hand. Rationale: The client's daughter's presence may make the procedure safer and less traumatic. ___Wrong Answers___ a. Tell the daughter that this may be traumatic so it is best for her to wait outside the room. **This should not be the nurse's decision and is not the most therapeutic response. c. Ask the client if he wants the daughter to stay in the room for the procedure. **The client is confused, afraid, and disoriented. Asking his permission may worsen his symptoms. d. Explain how clients generally follow staff requests if family members are not present. **The client is confused, and he needs a familiar face to help him feel safe.
What information is most important to find out from the client's daughter before developing the plan of care to address caregiver role strain? a. Ask how is the rest of the family coping with their father's illness. b. Identify what the daughter feels is most stressful in her daily life. c. Find out if the daughter has attended a caregiver support group. d. Evaluate how much time do the daughter spends taking care of herself.
b. Identify what the daughter feels is most stressful in her daily life. Rationale: This question will focus the caregiver on the daughter's needs. ___Wrong Answers___ a. Ask how is the rest of the family coping with their father's illness. **This will provide useful information, but does not address the daughter's stress. c. Find out if the daughter has attended a caregiver support group. **This will provide useful information, and may help in the long term but a short term goal needs to be identified. d. Evaluate how much time do the daughter spends taking care of herself. **This will provide useful information, but may make the daughter feel as if she is not totally devoted to her father. Submit
"During the course of his hospitalization, the client naps frequently during the day, has difficulty sleeping at night, and becomes afraid, particularly when the nurse enters the room. The nurse recognizes that the client's symptoms are consistent with the delirium sundowning phenomenon also known as "sundown syndrome." Which action should the nurse take? a. Encourage increased physical activity 1 hour before bedtime. b. Keep the room well lit during the evening hours. c. Provide a mild stimulant such as coffee during the day to reduce afternoon napping. d. Contact the HCP and request a sedative for nighttime use to promote sleep.
b. Keep the room well lit during the evening hours. Rationale: Adequate lighting can decrease agitation that occurs when surroundings are unfamiliar or dark. Reduced lighting and increased shadows can cause the client with Alzheimer's disease to misinterpret what they see. ___Wrong Answers___ a. Encourage increased physical activity 1 hour before bedtime. **Activity during the day may help symptoms of sundowning; however, it should not be encouraged within 4 hours of bedtime or it may interfere with sleep. c. Provide a mild stimulant such as coffee during the day to reduce afternoon napping. **Stimulants such as nicotine, alcohol, caffeine, and sweets should not be consumed after morning hours or they may interfere with sleep. d. Contact the HCP and request a sedative for nighttime use to promote sleep. **Non-Pharmacological measures work best for clients with Alzheimer's disease who are experiencing symptoms of sundowning.
Which is the best response by the nurse to the client's statement? a. Tell the client that there is nothing to worry about. b. Emphasize to the client that anxiety is common when people have problems remembering things and that he will be fine. c. State how worried the client looks and ask the how to make them more comfortable. d. Remind the client that he has Alzheimer's disease and has become more forgetful lately.
c. State how worried the client looks and ask the how to make them more comfortable. Rationale: **This response acknowledges the clients feelings and the word "worried" is generally neutral.** a. Tell the client that there is nothing to worry about - This response belittles the client's feelings and does not address his anxiety. b. Emphasize to the client that anxiety is common when people have problems remembering things and that he will be fine - Although it is common for clients to be anxious when they are confused secondary to memory loss, pointing this out may make him defensive and more anxious. d. Remind the client that he has Alzheimer's disease and has become more forgetful lately - The nurse does not know what the client understands about his diagnosis, and being too direct may make the client defensive and more anxious.
"The RN team leader meets with the home health PN about the client's care." Which finding is most important for the PN to report to the team leader? a. The client's skin becoming dry and flaky. b. How long it is not taking for the client to finish a meal. c. The weak and thready quality of the client's pulse. d. How the client rejects foods that he previously liked.
c. The weak and thready quality of the client's pulse. Rationale: A weak and thready pulse may indicate severe vascular dehydration and should be reported immediately. ___Wrong Answers___ a. The client's skin becoming dry and flaky. **Dry and flaky skin may indicate dehydration and should be reported, but this is not the most critical finding. b. How long it is not taking for the client to finish a meal. **It is not uncommon for individuals with Alzheimer's disease to become distracted while eating. The nurse can provide tips to increase nutrition, but this is not the most critical finding. d. How the client rejects foods that he previously liked. **This is common among individuals with Alzheimer's disease and can affect nutrition, but it is not the most critical finding. Submit Previous Section
Which finding by the nurse is most concerning? a. The client sloshes milk from the side of the glass when he sets it down. b. The client watches his daughter eat and mimics her as she takes a bite. c. The client reaches for the plastic fruit used in the table's centerpiece. d. The client's eyes water and face becomes red each time he swallows a bite of meat or bread.
d. The client's eyes water and face becomes red each time he swallows a bite of meat or bread. Rationale: Watering eyes during swallowing could indicate silent aspiration or choking, and it requires immediate medical evaluation. During the late stages of Alzheimer's disease, individuals can lose the mechanical ability to swallow, and they are at increased risk for aspiration. ___Wrong Answers__ a. The client sloshes milk from the side of the glass when he sets it down. **It is not uncommon for an individual with Alzheimer's disease to lose dexterity. Adapted serving dishes and utensils are available to make eating easier. This is not the most critical piece of information. b. The client watches his daughter eat and mimics her as she takes a bite. **The "watch me" technique is often used to encourage nutritional intake and to help the individual with Alzheimer's disease understand how to eat; therefore, this is not the most critical piece of information. c. The client reaches for the plastic fruit used in the table's centerpiece. **Confusion and distraction are not uncommon; therefore, this is not the most critical information. The nurse should tell the client's daughter to avoid placing other items on the table.