Ch. 24 Cognitive Disorders M.C.
Which of the following statements by the caregiver of a client newly diagnosed with dementia requires further intervention by the nurse? "I will remind Mother of things she has forgotten." "I will keep Mother busy with favorite activities as long as she can participate." "I will try to find new and different things to do every day." "I will encourage Mother to talk about her friends and family."
"I will try to find new and different things to do every day."
The geriatrician has prescribed an 80-year-old client donepezil in order to treat the client's dementia, Alzheimer's type. Which teaching points should the nurse provide to the client's spouse about the new medication? "It's important to closely follow the administration schedule for this drug if it is to make your spouse recover." "Donepezil will help your spouse sleep much better at night and stay awake during the day." "This won't result in any improvements to the client's symptoms of dementia of Alzheimer's type, but it will make the client much more compliant and easier to manage." "Donepezil won't cure your spouse's dementia of Alzheimer's type, but it has the potential to slow down the progression of the disease."
"Donepezil won't cure your spouse's dementia of Alzheimer's type, but it has the potential to slow down the progression of the disease."
A nurse is working with a client, and family of the client, who has a diagnosis of Alzheimer's disease. The nurse explains to the client and family that the average course of the disease is how many years? 10 15 20 25
10
The nurse understands that numerous comorbidities can contribute to the development of dementia. Which client may be at risk for dementia? A 69-year-old client whose lung cancer has metastasized to the bones and liver A 30-year-old client with schizophrenia who has been admitted to the hospital because of psychogenic polydipsia An 87-year-old resident of a long-term care facility who has developed a urinary tract infection (UTI) A 49-year-old client whose human immunodeficiency virus (HIV) has progressed to acquired immunodeficiency syndrome (AIDS)
A 49-year-old client whose human immunodeficiency virus (HIV) has progressed to acquired immunodeficiency syndrome (AIDS)
Which medication is not known to cause delirium? Antidepressants Steroids Loop diuretics Narcotics
Loop diuretics
A group of nursing students is reviewing information about delirium and its causes. The students demonstrate a need for additional review when they identify which as a cause of this medical condition? Infection Electrolyte imbalance Medications Oxidative stress
Oxidative stress
A client is diagnosed with Alzheimer's disease. While assessing the client, the nurse notes that the client has trouble identifying objects such as a key and spoon. The nurse would document this as what? Apraxia Disturbance of executive function Agnosia Aphasia
Agnosia
When assessing a client with dementia, the nurse notes that the client is having difficulty identifying common items, such as a ball or book. The nurse interprets this finding as what? Agnosia Aphasia Apraxia Disturbance of executive function
Agnosia
Which of the following interventions is most appropriate in helping a client with early-stage dementia complete ADLs? Allow enough time for the client to complete ADLs as independently as possible Provide the client with a written list of all the steps needed to complete ADLs. Plan to provide step-by-step prompting to complete the ADLs. Tell the client to finish ADLs before breakfast or the nursing assistant will do them.
Allow enough time for the client to complete ADLs as independently as possible.
What is the primary sign of delirium? Disturbed sleep-wake cycles An altered level of consciousness Impaired socialization Inability to fulfill roles
An altered level of consciousness
When conducting a nursing assessment of a client experiencing moderate cognitive dysfunction, the nurse can best prepare for an effective interview by ensuring what? Being sure the client is well rested before beginning the interview Breaking up the assessment into several short periods rather than a continuous one Sitting beside the client and using touch to be supportive Asking a family member to be present during the assessment
Asking a family member to be present during the assessment
A client has vascular neurocognitive disorder. When teaching the family about the cause of this disorder, which would the nurse expect to integrate into the explanation? Strands of protein are tangled together. Blood flow in the vessels to the brain are blocked. Fragments mix with molecules to make plaques in the brain. Acetylcholine production is decreased.
Blood flow in the vessels to the brain are blocked.
A client with a medical diagnosis of dementia of Alzheimer's type has been increasingly agitated in recent days. As a result, the nurse has identified the nursing diagnosis of "risk for injury related to agitation and confusion" and an outcome of "the client will remain free from injury." What intervention should the nurse use in order to facilitate this outcome? Apply restraints and place the client in seclusion as necessary. Set limits with the client around behavior. Monitor amount of environmental stimulation and adjust as needed. Explain to the client the relationship between agitation and injury.
Monitor amount of environmental stimulation and adjust as needed.
A client is diagnosed with dementia that has progressed significantly. Which would be the priority for this client? Education Cognitive interventions Safety Support
Safety
A group of friends have arrived at the hospital to visit a client recently diagnosed with delirium. The nurse tells the friends they can visit with the client one at a time. What is the likely reason for the nurse to give this instruction? The nurse wants to prevent increasing the client's confusion. The nurse wants the client to maintain an adequate balance of activity and rest. The nurse wants the client to demonstrate good orientation. The nurse wants to ensure the client's safety.
The nurse wants to prevent increasing the client's confusion.
The nurse preparing an educational program on dementia should include which information? The onset of symptoms of dementia is gradual Delirium involves progressive deterioration of intellect Dementia has many different causes Delirium is the most debilitating condition seen in the older population
The onset of symptoms of dementia is gradual
After educating a group of nurses on Alzheimer's disease and appropriate nursing care, the group leader determines that the education was successful when the nurses identify which as the foundation for providing care to the client and family? Functional independence Therapeutic relationship Injury prevention Medication therapy
Therapeutic relationship
Which can be identified as a hallmark symptom of dementia? Clients with these disorders tend to confabulate This class of disorders does not involve memory loss Long-term memory affected most Short-term memory loss
Short-term memory loss
The nurse receives a report that a 75-year-old client is recovering from surgery. During the shift, the nurse notes that the client is forgetful and restless. Several times, the client calls the nurse the name of the client's daughter. The nurse interprets this behavior as what? Normal, given the client's age Signs of early Alzheimer's disease Signs of delirium Normal for the first postoperative day
Signs of delirium
What is the initial intervention the nurse should implement when helping a client diagnosed with dementia deal with paranoid delusions? ask that the client be prescribed medication to help manage the paranoia explain to the client that his or her fears are unfounded observe the client in order to identify the triggers for the delusions keep the client occupied when he or she first begins to express the delusion
observe the client in order to identify the triggers for the delusions
An older adult with no significant medical history is admitted to the hospital through the emergency department after hitting the client's head during a fall and fracturing the humerus. The client does not require surgery and will probably be discharged the following day. Should the nurse be concerned about delirium? No, because the client does not have an underlying disease process Yes, because the client is in an unfamiliar environment and overstimulated No, because the client will not be hospitalized long enough to develop delirium Yes, because of the head injury and medication
Yes, because of the head injury and medication
An 80-year-old is brought to the clinic by the client's spouse. The client has a history of peripheral vascular disease and type 2 diabetes. The spouse states that the client hasn't seemed to be normal for the preceding few days, noting that the client has been lethargic and mildly confused at times and has been incontinent of urine. The spouse reports that the client's blood glucose levels have been elevated. The nurse considers which as the most likely explanation for the client's change in mental status? Delirium related to underlying medical problem Depression related to declining health Transient ischemic attacks related to vascular disease and diabetes Dementia related to advancing age
Delirium related to underlying medical problem
Changes that are found during the mental status examination of a client diagnosed with delirium include what? Difficulty focusing Increased attention to detail Clear memory No impairment of consciousness
Difficulty focusing
A group of nurses is reviewing information about delirium and dementia. The nurses demonstrate a need for additional review when they identify which as a characteristic of dementia? Normal psychomotor activity Possible hallucinations Fluctuating changes within a 24-hour period Globally impaired cognition
Fluctuating changes within a 24-hour period
Which is the hallmark of beginning mild dementia? Depression Restlessness Anxiety Forgetfulness
Forgetfulness
A client with Alzheimer's disease is admitted to an acute care facility for treatment of an infection. Assessment reveals that the client is anxious. When developing the client's plan of care, which would be least appropriate for a nurse to include? Simplify the client's routines Frequently provide reality orientation Limit the number of choices to be made Establish predictable routines
Frequently provide reality orientation
A nurse is providing education to the care provider of a cognitively impaired client who is prescribed a cholinesterase inhibitor. Which information about medication side effects should the nurse be sure to include? Syncope Skin rashes Gastrointestinal (GI) symptoms Bruising
Gastrointestinal (GI) symptoms
The adult child of a client with dementia asks the nurse how the adult child should respond when the client repeatedly says the client has had a busy day at work. The client has not worked in over 20 years. Which is the best guidance that the nurse could offer? Ask the client to explain what the client did at work today that kept the client busy. Go along with the client's thought of it having been a busy day, but do not refer to the client's work. Reorient the client that the client is at home and did not go to work. Give the client 5 to 10 minutes of rest, and the client will have no memory of the incident.
Go along with the client's thought of it having been a busy day, but do not refer to the client's work.
A client with amnestic disorder is being evaluated for dementia. Which is a diagnostic characteristic of amnestic disorder? Memory minimally decreased from usual No significant problems with occupational or social functioning Memory impairment limited to periods of delirium History and physical examination indicative of memory impairment
History and physical examination indicative of memory impairment
A nurse is preparing a presentation for a group of staff nurses about neurocognitive disorders. When describing vascular neurocognitive disorder, the nurse would identify which as posing the greatest risk for this disorder? Hyperlipidemia Diabetes Heart disease Hypertension
Hypertension
Which is the primary treatment for delirium? Maintain intravenous fluid administration Provide adequate nutritional food and fluid intake Identify and treat any causal or contributing medical conditions Apply physical restraints
Identify and treat any causal 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 cowers. Which feature of delirium is this client exhibiting? Hallucination Misinterpretation Euphoria Illusion
Illusion
Cognitive disorders are characterized by what? Impaired adjustment to stressful events Negative self-talk and poor coping skills Distorted self-image Impaired attention, memory, and abstract thinking
Impaired attention, memory, and abstract thinking
Which is the most effective intervention for clients with delirium? Giving detailed explanations Managing environmental stimuli Promoting rest with PRN medications Providing activities for distraction
Managing environmental stimuli
While reviewing the medical record of a client with moderate dementia of the Alzheimer's type, a nurse notes that the client has been receiving memantine. The nurse identifies this drug as which type? Atypical antipsychotic NMD receptor antagonist Cholinesterase inhibitor Benzodiazepine
NMD receptor antagonist
A client has experienced a gradual flattening of affect, confusion, and withdrawal and has been diagnosed with Alzheimer's disease. Which additional findings would the nurse most likely assess? Uncharacteristic use of illicit substances and alcohol Personality change, wandering, and inability to perform purposeful movements Transient blindness, slurred speech, and weakness Tremors, unsteady gait, and transient paresthesias
Personality change, wandering, and inability to perform purposeful movements
A client is in the mild stage of dementia due to Alzheimer's disease. Which intervention would be most appropriate? Advocating for the client to be transitioned to a care home Suggesting new activities for the client and family to do together Providing emotional support and gentle reminders Offering nourishing finger foods to help maintain the client's nutritional status
Providing emotional support and gentle reminders
During morning care, a nursing assistant asks a client with dementia, "How was your night?" The client replies, "It was lovely. My husband and I went out to dinner and to a movie." The nurse, who overhears this conversation, would make which assessment regarding the client? The client is demonstrating a sense of humor. The client is using confabulation. The client is perseverating. The client is delirious.
The client is using confabulation.
A new nurse has been working with clients with Alzheimer's disease for almost 6 months. During a staff meeting, the nurse expresses frustration because the same instructions have to be given to clients on a daily basis. The nurse states, "I feel like all my work doesn't do them any good." Which suggestion would be most appropriate for the supervisor to make initially? Cease giving instructions because the clients will not remember them anyway. Try to stay supportive and meet the clients' needs at the current moment. Seek counseling if personal feelings get in the way of client care. Consider transferring to a different client care specialty area.
Try to stay supportive and meet the clients' needs at the current moment.
The nurse is working with the family of a client who is newly diagnosed with Alzheimer's type dementia. Which suggestion would be effective for assisting the family members in daily orienting of their family member when the client returns home? Provide a flexible schedule and change the activities each day. Use daily newspapers, calendars, and a set routine. Read to the client for long periods at a time. Use a daily current events quiz, making sure that the client participates.
Use daily newspapers, calendars, and a set routine.
To manage voiding issues, such as incontinence, male clients diagnosed with dementia would best be managed by what? Use of disposable, adult diapers Intermittent catheterization Condom catheter Indwelling catheters
Use of disposable, adult diapers
A client in the client's 50s has contacted the care provider because of concerns for the client's spouse, who has suddenly begun behaving uncharacteristically in recent days. Most recently, the spouse became lost while driving to the spouse's home of 30 years and temporarily forgot the name of the spouse's child. Diagnostic testing has ruled out delirium and the spouse had been previously healthy. What is the most likely cause of the spouse's cognitive changes? Wernicke's encephalopathy Dementia of Alzheimer's type (DAT) Vascular dementia Dementia with Lewy bodies (DLB)
Vascular dementia
A client has contacted the care provider because of concerns for the client's 55-year-old spouse, who suddenly became very forgetful in recent days. Most recently, the spouse became lost while driving to the spouse's home of 30 years and temporarily forgot the client's adult child's name. The client also had a temporary slurring of speech lasting about a minute. Diagnostic testing has ruled out delirium and the spouse had been previously healthy. Which would the nurse most likely suspect? Alzheimer's disease Vascular neurocognitive disorder Neurocognitive disorder with Lewy Bodies Frontotemporal neurocognitive disorder
Vascular neurocognitive disorder
Which type of hallucination most commonly occurs in clients diagnosed with dementia? Gustatory Olfactory Auditory Visual
Visual
The nurse documents that a client diagnosed with dementia of the Alzheimer's type is exhibiting agnosia when the client is observed being unable to ... identify a picture of a car. find words to describe the client's daughter's appearance. open juice and insert a straw into the container. button a blouse.
identify a picture of a car.
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 ask that the client be prescribed medication to help manage the paranoia explain to the client that his or her fears are unfounded keep the client occupied when he or she first begins to express the delusion
observe the client in order to identify the triggers for the delusions
A nurse is caring for a client with delirium who is experiencing illusions. What environmental conditions should the nurse arrange for this client? Provide a well-lit room without glare or shadows and limit noise Have the client sit by the nurse's desk while awake in a room with the television on Light the room brightly around the clock and awaken hourly to check mental status Keep the room shadowy with soft lighting around the clock, and keep a radio on continuously
provide a well-lit room without glare or shadows and limit noise
What is the greatest benefit support groups provide to the caregivers of clients diagnosed with dementia? provides time away from the client provides interaction with those with similar concerns provides resources for needed services provides a social outlet
provides interaction with those with similar concerns
A client was admitted to the intensive care unit after a motor vehicle accident. The client sustained a right parietal injury, resulting in an acute confusional state or delirium. The client reports that there are "bugs crawling around" on the arms. The nurse understands this as: preexisting schizophrenia. tactile hallucinations from delirium. increasing brain damage and poor prognosis. a predisposition to such episodes early in the morning.
tactile hallucinations from delirium.
Which client behavior should the nurse attempt to change when managing a client's tendency to wander and pace at night? watch television after dinner insist on having the curtains left open at night request a bedtime snack of milk and cookies take a nap mid-afternoon and before dinner
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 adolescent who is hitting and biting because he or she was given time out for disobeying unit rules the middle-aged adult who is convinced that the electrical cords are really snakes the young adult who is expressing concern about the "police being aliens" the older widower who is worried about his wife not being able to visit because of the snow
the older widower who is worried about his wife not being able to visit because of the snow
A nurse is caring for a client diagnosed with delirium who has been brought for treatment by the client's adult child. While taking the client's history, which question would be most appropriate for the nurse to ask the client's adult child? "Has your parent experienced any major losses recently?" "Are you aware of your parent falling or injuring the head in any way?" "Has your parent had a recent stroke?" "Has your parent taken any medications recently?"
"Has your parent taken any medications recently?"
A 73-year-old client has been brought to the emergency department by the client's adult children due to abrupt and uncharacteristic changes in behavior, including impairments of memory and judgment. The subsequent history and diagnostic testing have resulted in a diagnosis of delirium. Which teaching point about the client's diagnosis should the nurse provide to the family? "If the underlying cause of delirium is identified and treated, most people return to their previous level of functioning." "The treatment that the care team will likely provide is simple rest, which will probably bring about a return to normal." "Delirium can be caused by a wide variety of factors but most of the changes in behavior and personality are permanent." "For many older adults, this is considered to be just a normal part of the aging process."
"If the underlying cause of delirium is identified and treated, most people return to their previous level of functioning."
The nurse is assessing a client who has received a tentative diagnosis of delirium. The nurse is explaining to the family about the major cause of the client's condition. Which statement by the nurse would be most appropriate? "The client's exposure to an infectious agent led us to determine the diagnosis." "Basically, this diagnosis is based on the client's inability to talk normally." "Your report of gradually developing confusion over time was the basis for the diagnosis." "The client's diagnosis is primarily based on the rapid onset of the change in consciousness."
"The client's diagnosis is primarily based on the rapid onset of the change in consciousness."
A client diagnosed with Alzheimer's disease says, "I'm so afraid. Where am I? Where is my family?" How should the nurse respond? "I just told you that you're in the hospital and your family will be here soon." "You are in the hospital and you're safe here. Your family will return at 10 o'clock, which is 1 hour from now." "You know where you are. You were admitted here 2 weeks ago. Don't worry; your family will be back soon." "The name of the hospital is on the sign over the door. Let's go read it again."
"You are in the hospital and you're safe here. Your family will return at 10 o'clock, which is 1 hour from now."
A 35-year-old client is delirious after being lost in the woods for several days and becoming severely dehydrated. At 9 p.m. the client tells the nurse to get the client's clothes because the client has to get home to the client's family. Which response by the nurse is most therapeutic? "It's time to sleep now; you can see your family in the morning." "You're in the hospital. You did not drink for several days, but you're getting better now." "We don't have your clothes; they are at home. You'll be going home when you recover." "Your family is fine. You need to take care of yourself now."
"You're in the hospital. You did not drink for several days, but you're getting better now."
Parkinson's disease is thought to be caused by which neural change? Too many dopamine receptors in the cerebellum A loss of neurons at the basal ganglia Overproduction of dopa, which responds to treatment with its antagonist, L-dopa Prolonged availability of dopamine at the synaptic cleft
A loss of neurons at the basal ganglia
In clients with Alzheimer's disease, neurotransmission is reduced, neurons are lost, and the hippocampal neurons degenerate. Which neurotransmitter is most involved in cognitive functioning? Norepinephrine Acetylcholine Serotonin Epinephrine
Acetylcholine
Which would not be considered a primary goal of nursing care for a client with delirium? Meeting physiological and psychological needs Protection from injury Management of confusion Achievement of self-esteem needs
Achievement of self-esteem needs
The nurse is caring for a client with dementia. The client's brain images show atrophy of cerebral neurons and enlargement of the third and fourth ventricles. What is the cause of dementia in this client? Alzheimer's disease Picks's disease Vascular dementia Parkinson's disease
Alzheimer's disease
The nurse is performing an admission assessment for a client who is suspected of having dementia. Which finding would the nurse most likely document as a subjective finding? Answers by the client and family to questions about emotional changes Assessment of the client's level of consciousness Client's ability to perform arithmetic problems to determine cortical function Results of testing the client's ability to remember unrelated words and recent events
Answers by the client and family to questions about emotional changes
A client diagnosed with Alzheimer's disease has an alteration in language ability. This alteration would be documented as what? Aphasia Apraxia Akinesia Agnosia
Aphasia
When giving tacrine to an elderly client, the nurse must be aware of what information? Tacrine works only in clients with late-stage dementia. The client will experience dry mouth and difficulty urinating. The most common side effects are headache and dizziness, so the client must be monitored for falls. Because the liver is most vulnerable to tacrine, liver function tests must be done periodically.
Because the liver is most vulnerable to tacrine, liver function tests must be done periodically.
When working with the family of an older adult client recently diagnosed with vascular dementia, the nurse's primary educational concern is to what? Explain the medication therapy the client has been prescribed Discuss the speed of progression of the disease's symptoms Determine ways to minimize caregiver stress Explain the onset can be related to exposure to infection
Discuss the speed of progression of the disease's symptoms
The spouse caregiver of a client with dementia tells the nurse that the client has been agitated lately. The spouse states, "I don't know how to handle this. The client was always such a gentle person!" Which interventions should the nurse suggest? Leave the client in a safe place in the house and go to another area until the client calms down. Distract the client with family photos and discuss the events pictured. Distract the client by turning on the television or watching a video. Give the client a sedative when the client begins to get agitated.
Distract the client with family photos and discuss the events pictured.
A client with Alzheimer's disease in the intensive treatment unit repeatedly tries to go into other clients' rooms to nap during the day. The most appropriate nursing intervention for this client is what? Allowing the client to nap in an empty room Explaining to the client why this cannot be tolerated Escorting the client to the client's room for napping Suggesting that daytime napping be decreased
Escorting the client to the client's room for napping
The client is an 84-year-old suffering from delirium. The client has been in a nursing home for the past 2 years but recently is becoming combative and has become a threat to staff. Which medication would the client most likely receive for these symptoms? Haloperidol Rivastigmine Galantamine Tacrine
Haloperidol
The grown daughter of a woman with Alzheimer's disease reports to the nurse that she is trying to keep her mother's condition from worsening by asking her questions whenever they are together. The nurse recognizes that this activity is likely to do which of the following? Decrease environmental misinterpretation Improve memory retention Increase frustration Slow the progress of the disease
Increase frustration
A client was admitted to an inpatient unit with a diagnosis of dementia. A nursing assessment and interview of the client would include what? Assessment of deep tendon reflexes and muscle strength Early parent-child conflict and relational patterns Electroencephalogram, X-rays, blood chemistries, and skull series Intellectual ability, health history, and self-care ability
Intellectual ability, health history, and self-care ability
Delirium can be differentiated from many other cognitive disorders in which way? It is characterized by a period of disorganization and confusion. It is much less responsive to pharmacologic treatment than the other disorders. It has a rapid onset and is highly treatable if diagnosed quickly. It has as a slow onset, but if caught early it can be treated with medications.
It has a rapid onset and is highly treatable if diagnosed quickly.
A client with dementia is having difficulty clearly communicating about physical needs. When teaching the caregiver about ways to assist the client in meeting physical needs, which instruction would the nurse most likely include? Give acetaminophen if the client appears uncomfortable. Keep a record of bowel movements. Ensure environmental noise for stimulation. Keep a record of emotional outbursts.
Keep a record of bowel movements.
The client is a 68-year-old who has been showing signs of Alzheimer's disease, including visual hallucinations and disturbed behaviors. When the client was placed on antipsychotic medications, the client suffered significant adverse reactions. This could indicate that the client does not have Alzheimer's disease, but which condition? Creutzfeldt-Jakob disease Pick's disease Lewy body dementia Huntington's disease
Lewy body dementia
A client is exhibiting signs of mild delirium such as occasional confusion about why the client is in the hospital and what day of the week it is. When developing a care plan, the nurse identifies several strategies to improve the client's cognitive function. Which intervention will be helpful to the client? Have someone play checkers with the client. Keep the television on to provide stimulation. Make up a daily calendar with the date and the times of scheduled activities. Have the client rest.
Make up a daily calendar with the date and the times of scheduled activities.
A client with dementia becomes extremely agitated shortly after being admitted to the psychiatric unit. The nurse is reluctant to use physical restraints to control the client. What is a likely reason the nurse has this reluctance? Physical restraints may potentially become fatal for the client. Physical restraints may not be of any use in controlling the client. Physical restraints may cause injury to the client. Physical restraints may increase the client's agitation.
Physical restraints may increase the client's agitation.
An older adult client develops delirium secondary to an infection. Which would be the most likely cause? Pneumonia Cellulitis Appendicitis Low platelet count
Pneumonia
The client has advanced Alzheimer's disease and becomes confused at mealtimes. The client has agnosia, apraxia, and disturbed executive functioning. Which is the most appropriate nursing intervention? Provide the client with a tray but encourage the client to open the client's own packages. Ask the client what the client would like from the buffet and give the client finger foods. Provide the client with a tray, opening containers for the client. Have the client eat in the client's room to avoid distractions while eating.
Provide the client with a tray, opening containers for the client.
A care aide has rung the call light for assistance while providing a client's twice-weekly bath because the client became agitated and aggressive while being undressed. Knowing that the client has a diagnosis of dementia of Alzheimer's type and is prone to agitation, which measure may help in preventing this client's agitation? Decreasing the frequency of the client's baths from two times to one time per week Reminding the client multiple times that he or she will be soon having a bath Reinforcing the facility's zero-tolerance policy for aggressive behavior Providing all of the client's daily medications early on the day of a scheduled bath
Reminding the client multiple times that he or she will be soon having a bath
The nurse is assessing a client who is diagnosed with delirium. Which presenting sign in the client indicates to the nurse that the client may have a diagnosis of dementia? Impaired consciousness Irrelevant speech Remote memory loss Visual hallucinations
Remote memory loss
Which nursing diagnosis would be the priority for the client experiencing acute delirium? Acute confusion related to delirium of known/unknown etiology Fall precautions related to acute confusion Risk for self-mutilation related to confusion and cognitive deficits Risk for injury related to confusion and cognitive deficits
Risk for injury related to confusion and cognitive deficits
Which nursing diagnosis would be the priority for the client experiencing acute delirium? Acute confusion related to delirium of known/unknown etiology Risk for self-mutilation related to confusion and cognitive deficits Fall precautions related to acute confusion Risk for injury related to confusion and cognitive deficits
Risk for injury related to confusion and cognitive deficits
The nurse is providing care to a client with dementia to meet the client's nutritional needs. Which approach would be most appropriate for the nurse to implement to assist in meeting adequate dietary intake? Sit with the client as long as necessary to complete the meal. Provide entertainment during meals such as television or music. Avoid between-meal snacks to encourage appetite. Serve meals in small, bite-size pieces.
Serve meals in small, bite-size pieces.
The client is 42 years old, married, and has two children, ages 16 and 18. The client is also caring for the client's parent, who is in the late stages of Alzheimer's disease. The nurse would want to assess the client for what? Early signs of Alzheimer's disease Likelihood to engage in elder abuse Signs of stress Signs of dominance
Signs of stress
The client is 42 years old, married, and has two children, ages 16 and 18. The client is also caring for the client's parent, who is in the late stages of Alzheimer's disease. The nurse would want to assess the client for what? Signs of stress Likelihood to engage in elder abuse Signs of dominance Early signs of Alzheimer's disease
Signs of stress
A client is diagnosed with dementia related to Parkinson's disease. While at a clinic visit, a cholinesterase inhibitor is prescribed for the client. The nurse knows that this type of medication would be prescribed for the client to achieve which goal? Increase the number of neurons in the brain Decrease combative behaviors and hallucinations Slow deterioration of memory and function Decrease tremors associated with Parkinson's disease
Slow deterioration of memory and function
An 82-year-old client with a diagnosis of vascular dementia has been admitted to the geriatric psychiatry unit of the hospital. In planning the care of this client, which outcome should the nurse prioritize? The client will demonstrate decreased agitation. The client will demonstrate increased feelings of self-worth. The client will identify life areas that require alterations due to illness. The client will remain free from injury.
The client will remain free from injury.
The psychiatric nurse documents that the cognitively impaired client is exhibiting "confabulation" when observed doing what? Pacing nervously and resisting the staff's request to "get ready for bed" Asking where the cats are when told it's "raining cats and dogs" Telling the staff repeatedly that "my name is George and I'm hungry" Telling other clients that the client "was a dairy farmer" when the client actually ran a small grocery store
Telling other clients that the client "was a dairy farmer" when the client actually ran a small grocery store
An older client comes to the clinic for a yearly physical exam. During the assessment, the client tells the nurse that the client sometimes has begun feeling anxious about the client's forgetfulness. The nurse notes the client may have mild dementia. Which finding would lead the nurse to conclude this? The client exhibits confusion The client reports having delusions The client reports an inability to perform complex tasks The client has difficulty finding words
The client has difficulty finding words
The client has early Alzheimer's disease. When asked about family history, the client relates that the client has two children who are both grown and who visit the client around the holidays each year. The nurse subsequently discovers that the client has one child who is currently assigned overseas and who has not been home for 2 years. Which would best describe the client's behavior? The client is confabulating, most likely to cover for memory deficit. The client demonstrates aphasia when discussing the client's children. The client is confused about the client's children and needs refocusing. The client is showing signs of agnosia in that the client is unable to name the client's children.
The client is confabulating, most likely to cover for memory deficit.
An 82-year-old client with a diagnosis of vascular dementia has been admitted to the geriatric psychiatry unit of the hospital. In planning the care of this client, which outcome should the nurse prioritize? The client will identify life areas that require alterations due to illness. The client will demonstrate decreased agitation. The client will remain free from injury. The client will demonstrate increased feelings of self-worth.
The client will remain free from injury.
The nurse is assessing a client with aphasia and notes the client may be exhibiting echolalia during their conversation. What signs does the nurse observe that leads to this conclusion? The client may echo whatever is heard. The client may repeat words or sounds over and over. The client may have extreme difficulty forming sentences. The client's speech may be vague and cannot be interpreted.
The client may echo whatever is heard.
The nurse is interviewing a 50-year-old with a suspected cognitive disorder. The client has a long history of alcoholism. When the nurse asks if the client is employed, the client replies that the client is currently employed as a conductor on a national railway system. The client's spouse takes the nurse aside and informs the nurse that the client hasn't worked for several years and never worked for the railway. The nurse attributes the client's answer to which explanation? The client is ashamed that the client is unemployed and is trying to cover for it. The client may have Korsakoff's syndrome. The client may have Alzheimer's disease. The client may be going through alcohol withdrawal.
The client may have Korsakoff's syndrome.
The nurse asks a client to pretend the client is brushing the client's teeth. The client is unable to perform the action. Upon examination, the nurse finds that the client possesses intact motor abilities. What can this problem be documented as? The client may have agnosia. The client may have apraxia. The client may have disturbed executive function. The client may have aphasia.
The client may have apraxia.
A 65-year-old has been admitted to the intensive care unit following surgical resection of the bowel. The client has developed a fever. Which additional signs indicate the client has developed delirium? The client identifies the client's fork as a spoon. The client cannot brush the client's teeth. The client has trouble remembering the client's birth date. The client removes the client's surgical bandage and begins picking at the sheets.
The client removes the client's surgical bandage and begins picking at the sheets.
Major goals for the nursing care of clients with dementia should include what? The client will have no self-harm behaviors and maintain sleep and appetite. The client will be safe and eat appropriately. The client will be safe, be physiologically stable, and have infrequent episodes of agitation. The client will be physically stable, maintain normal body weight, and be safe.
The client will be safe, be physiologically stable, and have infrequent episodes of agitation.
A 59-year-old has just been diagnosed with early-stage dementia. The client is experiencing mild forgetfulness but can function normally. The client lives with a spouse and adult child, who is a single parent of two. When planning care for this family, which of the goals should the nurse identify as a priority? The caregivers will demonstrate effective coping strategies to prevent burnout. The family will identify resources to meet caregiving needs. The client will discuss emotional response to diagnosis. The client will maintain self-care abilities as long as possible.
The client will discuss emotional response to diagnosis.
A nurse is caring for a client with delirium. The nurse assesses the client's activities of daily living on a daily basis. What is the most likely reason for assessing these so frequently? To assess for fluctuation in the client's capabilities To assess the prognosis of the client after therapy To ensure the client establishes a daily routine To ensure the client is involved in therapy
To assess for fluctuation in the client's capabilities
A nurse is studying the medical chart of a client with delirium. The nurse finds that the client was given haloperidol. What would be the most likely reason for administering this drug to the client? To improve dietary intake To minimize the effects of alcohol withdrawal To decrease agitation To sedate the client
To decrease agitation
Directed by evidence-based practice, the psychiatric nurse minimizes the milieu's dementia-induced aggressive behavior by: adhering to a predictable dressing routine. playing music with varied pitches during meal times. turning the television off at sundown. speaking to the clients in a soft voice.
adhering to a predictable dressing routine.