NURSING CARE OF CLIENTS WITH DISORDERS RELATED TO ALTERATIONS IN COGNITION AND PERCEPTION

A client with the diagnosis of schizophrenia plans an activity schedule with the help of the treatment team. After agreement by all, a written copy is posted in the client's room. When it is time of the client to go for a walk, what should the nurse say when approaching the client? 1. "It's time for you to go for a walk now." 2. "Do you want to take your scheduled walk now?" 3. "When would you like to go for your walk today?" 4. "You are supposed to be going for your walk now."

1. "It's time for you to go for a walk now." This message is concise and does not require decision making; it is less likely to increase anxiety.

A male client with schizophrenia has a history of hearing voices that tell him he is a bad person. While having a conversation with a nurse with whom he has been working, the client states that he is starting to hear the voices again. What is the best response by the nurse? 1. "Try to ignore the voices." 2. "What are the voices saying to you?" 3. "Don't believe what the voices are saying." 4. "Try not to be afraid because they are only voices."

1. "Try to ignore the voices." Clients can sometimes learn to push voices aside, particularly within the framework of a trusting relationship; it may provide the client wth a sense of power to manage the hallucinatory voices.

One evening the nurse finds a client, who has been experiencing persecutory delusions, trying to get out the door. The client states, "Please let me go. I trust you. The mafia is going to kill me tonight." Which response is most therapeutic? 1. "You are frightened. Come with me to your room and we can talk about it." 2. "Nobody here wants to harm you, you know that. I'll come with you to your room." 3. "Come with me to your room. I'll lock the door and no one will get in to harm you." 4. "Thank you for trusting me. Maybe you can trust me when I tell you no one can kill you while you're here."

1. "You are frightened. Come with me to your room and we can talk about it." This response recognizes the client's feelings and provides assurance that the staff member will be present.

When answering questions from the family of a client with Alzheimer's disease, the nurse explains, "This disease is: 1. A slow and relentless deterioration of the mind." 2. A functional disorder that occurs in the later years." 3. A disease that first emerges in the fourth decade of line." 4. Easily diagnosed through laboratory and psychologic tests."

1. A slow and relentless deterioration of the mind." This is a true statement; clients become progressively worse over time

A nurse is assessing client with dementia. Which client assessment is unexpected? 1. Acts pessimistic 2. Appears agitated 3. Has a short attention span 4. Exhibits disordered reasoning

1. Acts pessimistic A client who acts apathetic and pessimistic is demonstrating characteristics of depression, not dementia.

Geriatric clients with behavioral changes are often admitted to psychiatric unit for screening and evaluation. As part of the nursing assessment, it is important to observe for signs of dementia. The four "As" of Alzheimer's disease are: 1. Amnesia, apraxia, agnosia, aphasia 2. Avoidance, aloofness, asocial, asexual 3. Autism, loose association, apathy, affect 4. Aggressive, amoral, ambivalent, attractive

1. Amnesia, apraxia, agnosia, aphasia Neurofibrillary tangles in the hippocampus cause recent memory loss (amnesia); temporoparietal deterioration causes cognitive deficiencies in speech (aphasia), purposeful movement (apraxia), and comprehension of visual, auditory, and other sensations (agnosia).

The most appropriate way for the nurse to help a withdrawn, emotionally disturbed adolescent client to accept the realities of daily living is to: 1. Assist the client to care for personal hygiene needs 2. Encourage the client to keep up with school studies 3. Encourage the client to join the other clients in group singing 4. Leave the client alone when there appears to be disinterest int he activities at hand

1. Assist the client to care for personal hygiene needs Assisting clients with grooming helps keep them in contact with reality and allows them to see that staff members care enough to help. It also places value on appearance.

The nurse knows that prominent symptoms of lasting at least 1 month that are diagnostic for paranoid schizophrenia are: 1. Delusions and hallucinations 2. Poverty of speech with apathy 3. Bizarre behaviors associated with drug use 4. Disturbed relationships and poor grooming

1. Delusions and hallucinations Diagnostic criteria for paranoid schizophrenia include two or more symptoms such as delusions and hallucinations; other less prominent criteria are disorganized behavior and negative symptoms.

A male client with a history of schizophrenia comes to a mental health clinic for a regularly scheduled group therapy session. When the client enters the office, he is agitated and exhibits behaviors that indicate he is hearing voices. When the nurse begins to walk toward the client from across the room, the client pulls out a large knife. What is the best approach to use with this client? 1. Firm 2. Passive 3. Empathetic 4. Confrontational

1. Firm A firm approach prevent anxiety transference and provides structure and control for a client who is out of control.

Which is the best nursing intervention to encourage a withdrawn, non communicative client to talk? 1. Focus on nonthreatening subjects 2. Try to get the client to discuss feelings 3. Sit and look through magazines with the client 4. Ask questions that require "yes" or "no" answers

1. Focus on nonthreatening subjects Nursing care involves a steady attempt to draw the client into some response. This can best be accomplished by focusing on nonthreatening subjects that do not demand a specific response.

To achieve one of the primary objectives of providing a therapeutic daycare environment for a client who is withdrawn and seclusive, the nurse should: 1. Foster a trusting relationship 2. Administer medications on time 3. Involve the client in a group with peers 4. Remove the client from the family home

1. Foster a trusting relationship An interpersonal relationship based on trust must be established before clients can be helped back to reality.

When caring for client with exhibiting psychotic patterns of thinking and behavior, an important aspect of nursing care is to: 1. Help keep the client oriented to reality 2. Involve the client in activities throughout the day 3. Help the client understand that it is harmful to withdraw fro situations 4. Encourage the client to discuss why mixing with other people is being avoided

1. Help keep the client oriented to reality Keeping the withdrawn client oriented to reality prevents the client form withdrawing even further into a private world.

The nurse observes a dressed, emotionally disturbed client using the hands to eat soft foods The nurse can best intervene by: 1. Placing a spoon in the client's hand and suggesting it be used 2. Saying in a joking way, "Well, I guess fingers were made before forks." 3. Ingoring the behavior and observing several additional meals before intervening 4. Removing the food while saying, "You can't have any more until you use your spoon."

1. Placing a spoon in the client's hand and suggesting it be used The client needs limits to be set. This response sets limits and rejects the behavior but accepts the client.

What is the most appropriate nursing intervention when working with clients who exhibit mild cognitive impairment? 1. Reality orientation 2. Behavioral confrontation 3. Reflective communication 4. Reminiscence group therapy

1. Reality orientation Reality orientation is generally helpful to clients exhibiting mild cognitive impairment; these clients are aware of their impairment, and orientation then reduces anxiety.

An acutely ill client with the diagnosis of schizophrenia has just been admitted to the mental health unit. When working with this client initially, the nurse's most therapeutic action should be to: 1. Spend time with the client to build trust and demonstrate acceptance 2. Involve the client in occupational therapy and use diversional activity 3. Delay one-to-one interactions until medications reduce psychiatric symptoms 4. Involve the client in multiple small-group discussions to distract attention fro the fantasy world

1. Spend time with the client to build trust and demonstrate acceptance The initial goal should be to demonstrate acceptance and work toward developing trust; spending time with the client best meets this initial goal.

While watching TV in the day room, a female client who has demonstrated withdrawn, regressed behavior suddenly screams, bursts into tears, and runs out of the room to the far end of the hallway. What is the most therapeutic action for the nurse to take? 1. Walk to the end of the hallway where the client is standing 2. Accept the action as just being impulsive behavior of a sick person 3. Document the incident in the client's record while the memory is fresh 4. Ask another client who was in the day room what made the client act the way she did

1. Walk to the end of the hallway where the client is standing This lets the client known the nurse is available. It also demonstrates an acceptance of the client.

A client experiencing hallucinations tells the nurse, "The voices are telling me I'm no good." The client asks whether the nurse hears the voices. Which is the most appropriate response by the nurses? 1. "It is the voice of your conscience, which only you can control." 2. "No, I do not hear voices, but I believe you can hear them." 3. "The voices are coming from within you; only you can hear them." 4. "Hearing the voices are a symptoms of your illness; don't pay attention to them."

2. "No, I do not hear voices, but I believe you can hear them." The nurse, demonstrating knowledge and understanding, accepts the client's perceptions even thought they are hallucinatory.

A regressed, emotionally disturbed client who has been watching the nurse for a few days suddenly walks up and shouts, "You thing you're so damned perfect and good. I think you stink!" Which is the most appropriate response by the nurse? 1. "Do you mean I smell?" 2. "You seem angry with me." 3. "Boy, you're in a bad mood." 4. "I can't be all that bad, can I?"

2. "You seem angry with me." This response reflects on the client's feelings rather than focusing on the verbalization.

A client who experience auditory hallucinations agrees to discuss with the nurse alternative coping strategies. For the next 3 days when the nurse attempts to focus on alternative strategies, the client gets up and leaves the interaction. It is most therapeutic for the nurse to state: 1. "Come back; you agreed that you would discuss other ways to cope." 2. "You seem very uncomfortable every time I bring up a new way to cope." 3. "Did you agree to talk about other ways to cope because you thought that was what I wanted?" 4. "You walk out each time I start to discuss the hallucinations; does that mean you've changed your mind?"

2. "You seem very uncomfortable every time I bring up a new time to cope." This response focuses on a feeling that the client may be experiencing and provides an opportunity to validate the nurse's statement.

The nurse has been observing a client for some time. The client is delusional, talking about people who are plotting to do harm. The staff notices that the client is pacing more than usual. The nurse decides that the client is beginning to lose control. What is the best nursing intervention? 1. Encourage the client to use a punching bag 2. Move the client to a quiet place on the unit 3. Suggest that the client sit down for a while 4. Allow the client to continue pacing with supervision

2. Move the client to a quiet place on the unit Clients losing control feel frightened and threatened. They need external controls and a reduction in external stimuli.

An older adult is admitted to a psychiatric hospital with the diagnosis of dementia. The nurse recognizes that it would be most unusual for this client to demonstrate: 1. Resistance to change 2. Preoccupation with personal appearance 3. A tendency to dwell on the past and ignore the present 4. The inability to concentrate on new activities or interests

2. Preoccupation with personal appearance The client with delirium, dementia, or another cognitive disorder rarely expresses any concern about personal appearance. The staff must meet most of the client's needs in the area.

While the nurse is talking with a client, a female client comes up and yells, "I hate you. You're talking about me again," and throws a glass of juice at the nurse. What is the best nursing approach to respond to this situation? 1. Repeat the client's words and ask for clarification 2. Remove the client to her room because she needs limits placed on her behavior 3. Ignore both the behavior and the client, clean up the juice, and talk to her when she is better 4. Verbalize feelings of annoyance as an example to the client that it is more acceptable to verbalize feelings than to act-out

2. Remove the client to her room because she needs limits placed on her behavior The client's behavior is escalating and unsafe. She needs to be brought to her room, where there is decreased environmental stimulation and less chance for her to act-out against others.

A delusional client refuses to eat because of a belief that the food is poisoned. One of the most appropriate ways for the nurse to initially intervene is to: 1. Taste the food in the client's presence 2. Simply state the food is not poisoned 3. Show the client that other people are eating without being harmed 4. Tell the client that tube feedings will be started if eating does not begin

2. Simply state the food is not poisoned Clients cannot be argued out of delusions, so the best approach is a simple statement of reality.

A client diagnosed with schizophrenia is experiencing auditory hallucinations. The nurse makes the following statements when interacting with this client. Place these statements in the order in which they should occur. 1. "I do not hear any voices" 2. "Come with me for a walk" 3. "Hearing voices must be frightening." 4. "The voices you hear are part of your illness."

3, 4, 1, 2 The nurse should first identify the client's feelings (3); after identifying the client's feelings, the nurse should then simply explain why the voices occur (4); the nurse should then point out reality (1); finally, the nurse should attempt to distract the client from the hallucination (2)

A client is experiencing auditory hallucinations. The client tells the nurse, "I am a terrible, evil person; the voices are telling me that God needs to punish me." The most therapeutic initial response by the nurse is: 1. "God is loving and will not punish you." 2. "The voices you are hearing are just a fantasy." 3. "Tell me what you are thinking about yourself." 4. "You aren't a wicked person; God and I both love you."

3. "Tell me what you are thinking about yourself." Encouraging the client to focus on the self will facilitate communication and foster self-perception.

An older male client on the psychiatric unit becomes upset while in the day room. When attempting to help the client, what should be the nurse's initial intervention? 1. Instruct the client to be quiet 2. Allow the client to act-out until he tires 3. Give directions in the a firm, low-pitched voice 4. Lead the client from the room by taking him by his arm

3. Give directions a firm, low-pitched voice Clients who are out of control are seeking control and frequently respond to simple directions stated in a firm voice.

A 78-year-old male has been brought to the clinic by his family because they believe he has become increasing confused over the past week. What can the nurse ask the client to assess his orientation? 1. Explain a proverb 2. State where he was born 3. Identify the name of the hospital 4. Recall what he had eaten for breakfast

3. Identify the name of the hospital Orientation to place refers to an individual's awareness of the objective world in its relation to the self; orientation to time, place, and person are part of the assessment of cerebral functioning.

Th nurse understands that projection, rationalization, denial, and distortion by hallucinations and delusions are examples of disturbances in: 1. Logic 2. Association 3. Reality testing 4. Thought processes

3. Reality testing When individuals use these defense mechanisms, they are unable to test out their feelings or differentiate the real world from their personal intrapsychic perceptions.

During the admission procedure, a client appears to be responding to voices. The client crime out at intervals, "No, no, I didn't kill him. You know the truth; tell that policeman. Please help me!" The nurse should: 1. Listen attentively and assume a facial expression of disbelief 2. Sit there quietly and not respond to the client's statements 3. Respond by saying, "I want to help you. I realize you must be very frightened." 4. Say, "Do not become upset. No one is talking to you; the accusing voices are part of your illness."

3. Respond by saying, "I want to help you. I realize you must be very frightened." This response demonstrates an understanding of the clients's feelings and encourages the client to share feelings, which is an immediate need.

What is the nurse's most appropriate action when a client is seen openly masturbating in the recreation room? 1. Restraining the client's hands 2. Putting the client is seclusion 3. Stating that such behavior is unacceptable 4. Demonstrating no reaction to the behavior

3. Stating that such behavior is unacceptable The nurse should set limits on this behavior when it is not performed in a private area; this accepts the client but rejects the behavior. Also, limits may need to be set on this behavior when it is excessive.

When a regressed, emotionally disturbed client voids on the flood in the sitting room of the psychiatric unit, the nurse should intervene by: 1. Making the client mop the flood 2. Restricting the client's fluids throughout the day 3. Toileting the client more frequently with supervision 4. Withholding privileges each time the client voids on the floor

3. Toileting the client more frequently with supervision The client is voiding on the flood not to express hostility, but because of confusion. Taking the client to the toilet frequently limits voiding in inappropriate places.

The nurse enters a client's room and notes that the client appears preoccupied. Then, turning to the nurse, the clients states, "They are saying terrible things about me. Can't you hear them?" The most therapeutic response by the nurse is: 1. "It seems you heard them before?" 2. "Try to get control of your feelings." 3. "There is no on here but me, and I don't hear anything." 4. "I don't hear what you say you hear, but I can see you are upset."

4. "I don't hear what you say you hear, but I can see you are upset." This is the most therapeutic option; it interjects reality and focuses on the client's behavior.

A nurse is assigned to care for a regressed 19-year-old college student recently admitted to the psychiatric unit with a 1-month history of taking to unseen people and refusing to get out of bed, go to class, or get involved in daily grooming activities. The nurse's initial efforts should be directed toward helping the client by: 1. Providing frequent rest periods and avoiding exhaustion 2. Facilitating the client's social relationships with a peer group 3. Reducing environmental stimuli and maintaining dietary intake 4. Attempting to establish a meaningful relationship with the client

4. Attempting to establish a meaningful relationship with the client The first step in a plan of care should be the establishment of a meaningful relationship because it is through this relationship that the client can be helped.

The most serious indication of impending assaultive behavior is when the client: 1. Uses profane language 2. Touches people excessively 3. Exhibits a sudden withdrawal 4. Experiences command hallucinations

4. Experiences command hallucinations Command hallucinations are dangerous because they may influence the client to engage in behavior dangerous to self or others.

As the nurse enters a room and approaches a male client who has been diagnosed with schizophrenia, the client states, "Get out of here before I hit you! Go away!" The nurse recognizes that this client's aggressive behavior was probably related to the fact that he: 1. Felt hallucinating and the voices were directing his response 2. Was afraid that he might harm the nurse is the nurse came nearer 3. Was reminded of someone who was frightening and threatening to him 4. Felt hemmed in and trapped when the nurse came around the bed toward him

4. Felt hemmed in and trapped when the nurse came around the bed toward him Clients acutely ill with schizophrenia frequently do not trust others; feeling hemmed in may be frightening, causing them to last out.

It is important for nurses working with clients who have a diagnosis of dementia to adopt a common approach of care because these clients need to: 1. Relate in a consistent manner to staff 2. Learn that the staff cannot be manipulated 3. Accept controls that are concrete and fairly applied 4. Have sameness and consistency in their environment

4. Have sameness and consistency in their environment A consistent approach and consistent communication from all members of the health team help the client who has dementia to remain a bit more reality-oriented.

When caring for a client whose behavior is characterized by pathologic suspicion, the nurse should: 1. Remove the client fro environmental stress 2. Help the client realize the suspicions are unrealistic 3. Ask the client to explain the reasons of the feelings 4. Help the client to feel accepted by the staff on the unit

4. Help the client to feel accepted by the staff on the unit Delusions are protective and can be abandoned only when the individual feels secure and adequate. This response is the only one directed at building the client's security and reducing anxiety.

Observation is an important aspect of nursing care. It is especially important in the care of the withdrawn client because it: 1. Is useful in making a diagnosis 2. Tells the staff how ill the client is 3. Indicates the degree of depression 4. Helps in understanding the client's behavior

4. Helps in understanding the client's behavior By observing the client the nurse is better able to understand the clients behavior, which can be an indication of feelings.

A client with schizophrenia is admitted to an acute care psychiatric unit. Which positive signs and symptoms exhibited by this client should the nurse document? 1. Withdrawal, poverty of speech, inattentiveness 2. Flat affect, decreased spontaneity, asocial behavior 3. Hypomania, labile mood swings, episodes of euphoria 4. Hyperactivity, auditory hallucinations, loose associations

4. Hyperactivity, auditory hallucinations, loose associations These are positive symptoms associated with schizophrenia; positive symptoms reflect a distortion or excess of normal functions.

The nursing goal of the therapeutic psychiatric environment for the confused client is to: 1. Assist the client to relate to others 2. Make the hospital atmosphere more homelike 3. Help the client become popular in a controlled setting 4. Maintain the highest level of safe, independent functioning

4. Maintain the highest level of safe, independent functioning The therapeutic milieu is directed toward helping the client develop effective ways of functioning safely independently.

A 75-year-old man with the diagnosis of dementia has been cared for by his wife for 5 years. For the past 2 years he has not spoken and s incontinent of urine and feces. During the last month he has changed form being placid and easygoing to agitated and aggressive. He is admitted to a psychiatric hospital for treatment with psychopharmacology. Which is the priority nursing care while this client is in the psychiatric facility? A. Managing his behavior B. Preventing further deterioration C. Focusing on the n needs of the wife D. Establishing an elimination retraining program

A. Managing his behavior The client must be kept from harming himself or others; he needs a calm, supportive environment that meets his needs and maintains his dignity.

The nurse is assessing a client and attempting to distinguish between dementia and delirium. Which factors are unique to delirium? Select all that apply. A. Slurred speech B. Lability of mood C. Long-term memory loss D. Visual or tactile hallucinations E. Insidious deterioration in cognition F. Fluctuating levels of consciousness

A. Slurred Speech Delirium, a transient cognitive disorder caused by global dysfunction in cerebral metabolism, causes sparse or rapid speech that may be slurred and incoherent. D. Visual or tactile hallucinations Visual or tactile hallucinations and illusions may occur with delirium because of altered cerebral functioning; hallucinations are not prominent with dementia F. Fluctuating levels of consciousness Clients with delirium fluctuate from hyper alert to difficult to arouse; they may lose orientation to time and place; clients with dementia do not have fluctuating levels of consciousness, but they may be confused and disoriented.

A delirious client sees a design on the wallpaper and perceives it as an animal. The nurse should report this as an example of: A. A delusion B. An illusion C. A hallucination D. An idea of reference

B. An illusion An illusion is a misperception of misinterpretation of an actual external stimulus.

Which should the nurse include in the plan of care for the client with vascular dementia: A. A reeducation program B. Details for supportive care C. An introduction of new leisure-time activities D. Plans to involve the client in group therapy sessions

B. Details for supportive care Damaged brain cells do not regenerate. Care is therefore directed towards preventing further damage and providing protection and support.

Which nursing intervention is most helpful in meeting the needs of an older adult hospitalized with the diagnosis of dementia of the Alzheimer's type? A. Providing a nutritious diet high in carbohydrates and protein B. Simplifying the environment as much as possible while eliminating the need for choices C. Developing a consistent nursing plan with fixed time schedules to provide for emotional needs D. Providing an opportunity for many alternative choices in the daily schedule to stimulate interest

B. Simplifying the environment as much as possible while eliminating the need for choices Clients with this disorder need a simple environment. Because of brain cell destruction, that are unable to make choices.

When attempting to understand the behavior of an older adult diagnosed with vascular dementia, the nurse recognizes the the client is probably: A.Not capable of using any defense mechanisms B. Using one method of defense for every situation C. Making exaggerated use of old, familiar mechanisms D. Attempting to develop new defense mechanisms to meet the current situation

C. Making exaggerated use of old, familiar mechanisms These clients attempt to utilize defense mechanisms that have worked in the past but use them in an exaggerated manner. Because of brain cell destruction, these clients are unable to develop new defense mechanisms.

When conducting a mini-mental status exam on an older client, the nurse should test specifically for short-term memory by asking the client to: A. Subtract serial 7s from 100 B. Copy a simple geometric figure C. State three random words mentioned earlier in the exam D. Name two common objects when the nurse points to them

C. State three random words mentioned earlier in the exam This technique tests the client's ability to recall from short-term memory

The nurse's best approach when caring for a confused, older client is to provide an environment with: A. Space for privacy B. Group involvement C. Trusting relationships D. Activities that are varied

C. Trusting relationships A one-to-one trusting relationship is essential to help the client become more involved and interested in interpersonal relationships.

The nurse recognizes that dementia of the Alzheimer's type is characterized by: A. Aggressive acting-out behavior B. Periodic remissions and exacerbations C. Hypoxia of selected areas of brain tissue D. Areas of brain destruction called senile plaques

D. Areas of brain destruction called senile plaques When an older person's brain atrophies, some unusual deposits of iron are scattered on nerve cells. Throughout the brain, areas of deeply straining amyloid, called senile plaques, can be found; these plaques are end stages in the destruction of brain tissue.