Chapter 24 Videbeck

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

Which type of hallucination most commonly occurs in clients diagnosed with dementia?

visual

A client diagnosed with Alzheimer's disease says, "I'm so afraid. Where am I? Where is my family?" How should the nurse respond?

"You are in the hospital and you are safe here. Your family will return at 10 o'clock, which is in 1 hour from now"

A nurse is providing care to a client with dementia who is hyperactive. A diet high in which of the following would be most appropriate to include in the nutritional plan for this client? ~select all that apply~

- Carbohydrates - Protein

A client demonstrates an understanding about the risk factors for developing dementia when engaging in which health promotion activities? ~select all that apply~

- Eating a diet that provides sufficient amounts of B vitamins - Regularly reads fictional novels for entertainment - Does the daily newspaper crossword puzzle - Exercises at the gym 3 times a week

The nurse is caring for a client with delirium. Which interventions may help manage this client? ~select all that apply~

- Speak in simple sentences - Provide orienting verbal cues when talking with the client - Allow adequate time for the client to comprehend and respond

A nurse is giving instructions to a client diagnosed with delirium. What might the nurse repeat the instructions frequently? ~select all that apply~

- The client may have impaired attention - The client may have impaired recent and immediate memory

The nurse understands that numerous comorbidities can contribute to the development of dementia. Which of the following clients may be at risk for dementia?

A 49-year-old man whose HIV has progressed to AIDS

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

Achievement of self-esteem needs

What is the primary sign of delirium?

An altered level of consciousness

A client with dementia is having difficulty finding the words that he wants to use. When he could not remember the name of his shoes, he referred to them as, "the things you put on your feet." What is the name for this condition?

Aphasia

Which of the following terms is used to describe the inability to execute motor functioning, despite intact motor abilities?

Apraxia

When giving tacrine (Cognex) to an elderly client, the nurse must be aware of what information?

Because the liver is most vulnerable to tacrine, liver function tests must be done periodically

The wife caregiver of a client with dementia tells the nurse that her husband has been agitated lately. She states, "I don't know how to handle this. He was always such a gentle person!" Which of the following interventions should the nurse suggest?

Distract the client with family photos and discuss the events pictured

Which of the following is the hallmark of beginning mild dementia?

Forgetfulness

Which of the following is a metabolic cause of delirium?

Hypoglycemia

Which of the following is the primary treatment for delirium?

Identify and treat any casual or contributing medical conditions

A nurse is caring for a client with delirium. The client sees a thermometer on the nurse's table and shouts, "Don't stab me!" and then cowers. Which feature of delirium is this client exhibiting?

Illusion

Which of the following medications is not known to cause delirium?

Loop diuretics

Which of the following is the priority intervention for a client diagnosed with delirium?

Maintenance of safety

While reviewing the medical record of a client with moderate dementia of Alzheimer type, a nurse notes that the client has been receiving memantine. The nurse identifies this drug as which type?

NMDA receptor antagonist

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

Which of the following is an infection-related cause of delirium?

Pneumonia

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

Provides interaction with those with similar concerns

A client with Alzheimer's disease has a nursing diagnosis of risk for injury related to memory loss, wandering, and disorientation. Which nursing intervention should appear in this clients care plan to prevent injury?

Remove hazards from the environment

Which of the following medications, used to treat dementia, requires a liver function test every 1 to 2 weeks?

Tacrine (Cognex)

An older client comes to the clinic for a yearly physical exam. During the assessment the client tells the nurse that he sometimes has begun feeling anxious about his forgetfulness. The nurse notes the client may have mild dementia. Which finding would lead the nurse to conclude this?

The client has difficulty finding words

A woman in her fifties has contacted her HCP because of concerns for her husband, who has suddenly begun behaving uncharacteristically in recent days. Most recently, he became lost while driving to his home of 30 years and temporarily forgot his son's name. Diagnostic testing has ruled out delirium and he has been previously healthy. What is the most likely cause of the husband's cognitive changes?

Vascular dementia

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

Visual