CONCEPTS 3 WEEK 6

6) The nurse is caring for a child newly diagnosed with autism spectrum disorder (ASD). Which of the following is the most appropriate overall outcome for this child? A) To function more effectively in social and emotional interactions B) To stay on task C) To acknowledge the effects of personal behavior on others D) To acknowledge personal strengths

A) Autism spectrum disorders involve difficulties in the quality of both the social interaction and the communication of the child. In social interaction, the child may have problems making eye contact, fail to develop appropriate peer relationships, fail to spontaneously seek out shared enjoyment with other people, or show no social or emotional reciprocity. Children with spectrum disorders may or may not be able to acknowledge the effects of their behavior on others, stay on task, or acknowledge personal strengths.

5) The nurse is planning care for a client with stage 1 Alzheimer disease. Which are the priority nursing diagnoses for the client and family? A) Impaired Memory and Caregiver Role Strain B) Hopelessness and Functional Family Processes C) Knowledge Deficit and Ineffective Coping D) Pseudohostility and Ineffective Coping

A) Appropriate nursing diagnoses may depend on the stage of Alzheimer disease (AD). Impaired Memory is an appropriate nursing diagnosis in stage 1 AD. Caregiver Role Strain is appropriate for any stage of AD. Functional Family Processes and Ineffective Coping are not diagnoses related to cognitive behavioral assessment. Pseudohostility is not a nursing diagnosis.

5) An older adult client, hospitalized post-surgery, wakes up in the middle of the night very confused. The nurse reorients the client to the surroundings and gets the client to return to sleep. Which should the nurse consider as a source for the client's confusion? A) Ambien (zolpidem), a hypnotic/sedative, taken at bedtime for sleep B) The client's age C) The death of the client's husband last month D) History of cardiac disease

A) Certain medications, such as hypnotics/sedatives, anxiolytics, antidepressants, anti-Parkinson drugs, anticonvulsants, or antispasmodics, also increase symptoms of delirium. Therefore, the client's medication must be reviewed to determine the effects of drugs and cognitive changes. Although loss of a loved one may result in depression, it is unlikely to be the source of confusion. Age alone does not cause confusion, and cardiac disease alone would not cause confusion.

19) The nurse is teaching the family of a client who has just been diagnosed with dementia. The family asks if there are treatments available that will cure the client. What would be the nurse's best response to the family? A) "There are no treatments that will cure dementia at this time." B) "Treatments to cure dementia include the use of vitamin E." C) "Treatments to cure dementia involve hormone replacement therapy." D) "There are no treatments that can slow the progression of the disease."

A) Currently no treatment has been found to reverse or stop the pathologic process in progressive dementia. Studies on the use of dietary supplements such as antioxidant vitamins, gingko biloba, resveratrol, omega-3 fatty acids, and medical food such as tramiprosate (Vivimind) and caprylic acid for the management of AD are inconclusive at best and associated with risks such as interaction with other drugs and toxicity. There are two classes of medications used to slow the progression of the disease.

14) A nurse is caring for a client with Alzheimer disease (AD) who has receptive aphasia. Which area of the brain is likely damaged from AD? A) Temporal lobe B) Limbic system C) Frontal lobe D) Occipital lobe

A) Damage to the client's temporal lobe manifests as impaired memory, difficulty learning new things, and receptive aphasia. Damage to the limbic system manifests as loss of memory, fluctuating emotions, depression, and difficulty learning new information. Damage to the frontal lobe manifests as problems with intentional movement, fluctuating emotions, and loss of the ability to walk. Frontal lobe damage also causes loss of the ability to talk and the ability to swallow. Damage to the occipital lobe results in loss of reading comprehension and hallucinations.

1) A pediatric nurse is performing an assessment on a toddler who is suspected of having autism spectrum disorder (ASD). Which of the following questions to the parents would be least useful in gathering the information necessary to appropriately assess the toddler for this disorder? A) "Does your child have manic or depressed episodes?" B) "Tell me about your child's social interactions." C) "Does your child perform ritualistic behaviors when performing activities?" D) "Is your child able to name objects?"

A) Manic or depressed episodes are characteristics of bipolar disorder, not autism. Autism is characterized by social isolation, communication impairment, and strange repetitive behaviors.

10) A parent of a high school student with high-functioning ASD asks whether the child will ever be able to work. Which response by the nurse is best? A) "There are job training programs that assist adults with ASD." B) "Most adults with high-functioning ASD need to be supported by the state." C) "You should plan to provide care for your child for the rest of your life." D) "Individuals with high-functioning ASD usually grow out of the disorder."

A) Many communities provide job training and supervised work programs for adults with ASD. Although some adult patients with ASD do reside in group living environments, many live independently or with their parents. Many adults with ASD who cannot function independently or whose family can no longer provide care for them receive government subsidies, but there is no indication that this is the case for this client. It is incorrect to state that people can "grow out of" ASD.

1) An older adult client complains of periods of confusion and forgetfulness, but reports clear thought process at most times of the day. Which is the appropriate response from the nurse? A) "Are you having trouble hearing?" B) "You probably have nothing to worry about. It's most likely stress-related." C) "Everybody has a few problems with memory as they get older." D) "You should probably have an MRI of your brain."

A) People who cannot hear or see well often appear confused. The nurse should assess whether the client is having difficulty with these prior to moving on in the assessment process. Determine the degree of impairment and explore the possibility that this hearing impairment may be contributing to the client's confusion. A nurse should never discount the client's concerns, and memory loss with confusion and forgetfulness is not part of the normal aging process. The nurse needs to explore further before an expensive diagnostic study is considered. It would be beyond the scope of practice for the nurse to recommend this testing.

6) Which cognitive development theory proposes that all children progress through the same stages of development? A) Piaget B) Vygotsky C) Information-processing D) Erickson

A) Piaget's cognitive development theory proposes that all children progress through the same stages of development. Vygotsky's theory, on the other hand, discards the idea that all children progress through the same stages of development. Instead, Vygotsky theorized that skill development is influenced by the child's environment and culture. The information-processing theory views the mind as a computer that is always changing and evolving and takes in information, operates on it, and converts it to answers. Erickson's theory is not a cognitive development theory, but rather is a behavioral development theory.

13) A home health nurse visits a client with stage 2 Alzheimer disease who lives at home with a spouse. Which action by the nurse enhances the spouse's ability to meet the needs of the client? A) Encouraging the caregiver to obtain rest and eat a healthy diet B) Providing the client a list of daily activities to complete C) Making arrangements for the client to visit the local senior citizen center in the afternoon D) Finding placement in a long-term care facility

A) Stage 2 clients are generally more confused, can demonstrate repetitive behavior, are less able to make simple decisions and to adapt to environmental changes, and are often unable to carry out activities of daily living. The spouse needs opportunities to obtain the sleep and nutrition necessary to preserve personal health. Because the stage 2 client does not adapt well to changes in the environment, it would be best to have someone come into the home, rather than to have the client go out. An outing or a list of activities would be better suited for the client in stage 1. Recommending placement in long-term care might be premature and is not up to the nurse.

10) The nurse identifies a nursing diagnosis of Risk for Injury for a client who is disoriented. Which is an expected outcome for this client's care? A) The client does not sustain injuries during wanderings. B) The client remains continent of bowel and urine. C) The client receives culturally appropriate care. D) The client sleeps through the night and stays awake most of the day.

A) The client "does not sustain injury during wanderings" is the correct answer because it relates to the diagnosis and is measurable. The client "maintains continence on four out of five voidings" does not relate to the diagnosis. The client "sleeps through the night and stays awake most of the day" does not relate to the diagnosis. The client "receives culturally appropriate care" is an incorrect answer because expected outcomes are unknown and not measurable.

3) The nurse is caring for a family with four children whose third child has been diagnosed with attention-deficit/hyperactivity disorder (ADHD). Which statement made by the mother suggests that the family may have difficulty coping with this diagnosis? A) "I don't know how to tell the rest of the family, and I'm not sure how we will manage the other children." B) "We need to alert the teachers at school as soon as possible so they can work with us to develop a plan that meets my son's needs." C) "What does this mean for my son's health in the future?" D) "Given this diagnosis, I'm not sure if we should let our son act in the school play."

A) The mother's comments about how to tell the family and manage the other children suggest that the family may have difficulty adjusting to the child's diagnosis. This family will likely need assistance with coping with the child and continuing on with life. Alerting the teachers at school is a positive action and a way to protect the child. Decisions about participating in the school play should be discussed with the child's teachers, but the mother's statement does not suggest poor coping. Asking about the child's health in the future is reasonable at this time.

5) The nurse is caring for a young school-age child who was recently diagnosed with attention-deficit/hyperactivity disorder (ADHD). Which statement by the child's mother requires follow up teaching? A) "I will let my child do homework while watching a favorite television show." B) "I will give my child ADHD medication with meals." C) "I will take my child to the doctor every 3 months for a weight and height check." D) "I will stick to the same routine each day after school."

A) This child should do homework in a quiet environment, away from distractions. Giving ADHD medication with meals will help counteract the anorexia associated with this medication. Maintaining the same daily routine helps the child know expectations, and a nighttime routine helps counteract insomnia. Children with ADHD should be screened regularly for height and weight to monitor growth.

9) A client is diagnosed as having stage 1 Alzheimer disease. Which are appropriate goals for the client and family at this time? Select all that apply. A) Resolving grief over the diagnosis B) Deciding on the desired treatment and selecting a healthcare proxy; sharing the treatment decision with the healthcare proxy C) Beginning cognitive-enhancing medication, such as Aricept D) Setting up a protective physical environment—such as removing throw rugs E) Making provisions for assistance with activities of daily living (ADLs)

A,B,C,D Grieving over the diagnosis and loss of functioning and mental abilities will be an ongoing process for the client and the family members and is therefore a goal. While the client is still cognizant, it is important that the client and family discuss the desired treatment and designate a healthcare proxy to carry out the client's wishes regarding the treatment. Clients with early Alzheimer disease should start the cholinesterase inhibitor medication as soon as possible to extend the early stage of the disease. During this time period, the home environment should be modified to balance safety with client autonomy. Clients in stage 1 of Alzheimer disease continue to be proficient with ADLs and do not require assistance.

2) An adult child brings a parent in to be evaluated and is told the client has Alzheimer disease. The adult child asks the nurse if he is also at risk for the disease. Which risk factors should the nurse include when responding? Select all that apply. A) Genetic predisposition B) Age C) History of hypertension D) Hearing deficits E) Gender

A,B,C,E The most prominent risk factor for Alzheimer disease is advancing age. Individuals with a family history of AD are more likely to develop the disease, even in the absence of known genetic factors that predict or increase the risk of the disease. Research has identified risk factors of AD to include cardiovascular risks such as diabetes, mid-life obesity, mid-life hypertension, and hyperlipidemia. AD is almost three times more common in women than men. There is no indication that hearing deficits play a role in the development of Alzheimer disease.

4) A nurse is preparing an educational program for clients in a long-term care facility regarding protective factors for Alzheimer disease (AD). Which information should the nurse include? Select all that apply. A) Becoming involved in activities such as reading that keep the mind active B) Incorporate a high-calorie, high-carbohydrate diet to decrease formation of amyloid plaques C) Remain socially active D) Including modest exercise into daily regimen E) Begin drinking a glass of wine each night before bed

A,C,D ) Evidence demonstrates that cognitive activities such as reading, completing puzzles, and learning new information or tasks build cognitive resilience and protect against cognitive decline. There is some evidence to suggest that the heart-healthy diets that include antioxidant- and polyphenol-rich foods such as tea, cocoa, grapes, and colorful fruits and vegetables may interrupt formation of amyloid plaques and prevent AD. Social engagement may improve cognitive function and have some protective effects against AD. Modest levels of exercise have been demonstrated to improve cognitive function. Moderate alcohol consumption may be protective against AD. However, evidence is insufficient to suggest that individuals who do not already drink should start drinking.

7) The nurse is providing education to the parents of a child diagnosed with ASD. Which of the following healthcare professionals should the nurse tell the parents will take part in their child's care? Select all that apply. A) Social services B) Laboratory C) Speech therapy D) Play therapy E) Public health agency

A,C,D The goals of therapy are to facilitate communication, reduce rigidity, and treat maladaptive behaviors. To reach these goals, the child will be treated by a speech therapist, a play therapist, and social services. Laboratory technicians do not treat clients. A public health agency does not treat clients, although individuals who work there might.

5) A client with dementia is prescribed donepezil (Aricept). Which should the nurse consider when teaching this client about the medication? A) Donepezil shortens the early stages of Alzheimer disease. B) Donepezil is an acetylcholinesterase inhibitor that has a modest effect in slowing the progression of Alzheimer disease. C) Donepezil is an anticholinergic and has been known to eradicate some of the symptoms associated with Alzheimer disease. D) Donepezil should be taken on an empty stomach.

B) Acetylcholinesterase inhibitors reduce acetylcholine breakdown and have a modest effect in slowing an individual's rate of cognitive decline in Alzheimer disease. Symptoms are not eradicated, but progression is slowed. These medications should be taken on a full stomach, and antiemetic medications may also be needed.

8) The client is receiving risperidone (Risperdal) for the treatment of schizophrenia. Which client statement indicates the medication is effectively treating the positive symptoms of schizophrenia? A) "I promise not to skip breakfast anymore." B) "I am not hearing the voices anymore." C) "I will start going to group therapy." D) "I feel better and I am ready to go home."

B) Among the therapeutic effects of risperidone (Risperdal) is the remission of a range of psychotic symptoms that include delusions, paranoia, auditory hallucinations, and irrational behavior. A client stating he feels better and is ready to go home, stating he will go to group therapy, or stating he will not skip breakfast does not indicate the remission of any psychotic symptoms.

8) A nurse is caring for a child who has been diagnosed with attention-deficit/hyperactivity disorder (ADHD). The client's healthcare provider has prescribed amphetamine-dextroamphetamine (Adderall) to treat the child's disorder. Which of the following statements regarding the use of this medication is appropriate for the nurse to include in the medication teaching? A) "Your child's liver function should be monitored with this medication." B) "Your child's growth will need to be monitored on this medication." C) "This medication may increase the risk of psychosis." D) "This medication has less abuse tendency because it is not a stimulant."

B) Amphetamine-dextroamphetamine (Adderall), a psychostimulant, may delay the child's growth, and height should be monitored frequently. Liver function should be monitored with nonstimulant medications, not stimulants. Nonstimulants, not stimulants, may increase the risk of psychosis. Stimulant medications have a higher-not a lower-tendency to be abused.

6) A school-age client is hospitalized with encephalitis and is experiencing delirium. Which intervention promotes a therapeutic environment for this child and family? A) Making sure the parents perform all treatments for their child B) Encouraging the family to remain at the bedside with the client C) Making sure the child comes back for the follow-up appointment D) Providing written instructions before discharge

B) Besides the prevention and management of the underlying medical condition, the presence of parents and family members has been found to reduce the incidence of delirium. All of the other interventions are important for the discharge planning of this client.

4) The family of an older adult client is informed that the client has delirium. Which statement indicates that the family understands the diagnosis? A) "It's sad that dad is getting dementia." B) "The changes in his behavior came on so quickly, which may be the result of an underlying medical condition." C) "Our father is going to need long-term psychiatric care." D) "Confusion is normal in older adults, and it goes away on its own."

B) Delirium is characterized by a rapid and abrupt onset of symptoms and caused by an underlying medical condition. Once the medical condition is treated, the delirium resolves. Although delirium is more common in older individuals, aging is not a cause of delirium. Impairments in short-term memory are more indicative of dementia. The fact that he had been independent has no bearing on his current symptoms.

2) The nurse is assessing an older adult client and observes that the client is having several cognitive problems, including memory and attention deficits and fluctuating levels of orientation. The nurse confirms with the family that the client's symptoms developed over a several-year period. The client's symptoms are commonly observed with which condition? A) Depression B) Dementia C) Intellectual disability D) Delirium

B) Dementia is a chronic progressive disorder characterized by memory impairments that develop slowly over a longer period of time. Depression is a mood disorder that is characterized by a dysphoric mood or loss of interest in usual activities. Delirium is an acute, abrupt-onset condition characterized by prominent disorientation, impaired attention, and memory deficits. Intellectual disability is defined as significant limitation in intellectual functioning and adaptive behaviors that occurs before the age of 18.

3) A nurse is providing education to the caregiver of a child with autism spectrum disorder (ASD). Which commonly associated behavioral problem should be identified in this teaching? A) Depression in relation to feelings of inadequacy B) Episodes of self-injury C) Strong tendency toward hypoactivity D) Hostility when faced with structured environments or repetitive activities

B) Many children with a spectrum disorder have associated behavioral problems such as hyperactivity, aggressiveness, temper tantrums, and self-injurious behaviors like head banging. Problems with socialization and communication difficulties are also common, evidenced by deficits in spontaneous, imaginative play. These children typically have a restricted, repetitive repertoire of interests or behaviors, and therefore usually will not become depressed due to perceiving themselves as inadequate (although some children with high-functioning ASD may experience feelings of inadequacy). Many children with ASD will have difficulty adapting to change, so they will prefer structured environments and consistent schedules. These children also tend toward hyperactivity rather than hypoactivity, although this is not always the case.

7) A community health nurse is teaching a group of women about the dangers of smoking. Which of the following child health problems should the nurse mention as associated with smoking during pregnancy? A) Benzodiazepine withdrawal B) Attention-deficit/hyperactivity disorder (ADHD) C) Vision impairment D) Personality disorders

B) Maternal smoking during pregnancy is associated with an increased risk for ADHD in children. Smoking during pregnancy is not related to vision impairment, personality disorders, or benzodiazepine withdrawal.

3) The nurse is caring for a client who becomes confused and agitated every evening. Medical reasons for the change in mental status have been ruled out. The nurse correctly communicates to the other healthcare team members that the client is experiencing which phenomenon? A) Delirium B) Sundowning C) Aphasia D) Chronic psychosis

B) Sundowning is understood as confusion that intensifies in the evening or at bedtime. The client can become increasingly agitated, disoriented, or even aggressive/paranoid or impulsive and emotional later in the day and at night. Delirium is a rapid-onset type of confusion. Aphasia is the inability to use or understand language. Psychosis is a mental disorder, and this client is not exhibiting signs of psychosis.

1) The school nurse is talking to a child with attention-deficit/hyperactivity disorder (ADHD) who wants to play soccer. Which action is most appropriate for the school nurse to take? A) Recommend that the child become active in an individual sport, rather than a team sport. B) Encourage the child to play soccer. C) Discourage the child from playing a sport. D) Ask the child's mother to get permission from the child's physician to play soccer.

B) The child should be encouraged to play soccer. Participation in a team sport will assist the child with ADHD to expend some energy while cooperating with others and following game rules. Participating in a team sport can help promote self-esteem in the child with ADHD and encourage connectedness with other children. There is no reason for a child with ADHD not to play sports. The mother would not need physician approval for her son to play soccer. Vigorous physical activity is encouraged for all children with ADHD. Some of the benefits of participating in a team sport would not be available with individual sports.

18) A client presents with signs and symptoms of early Alzheimer disease. What would be used to confirm this client's diagnosis? A) Abnormal CT scan findings of plaques and tangles in the brain B) Client history and physical examination C) Positive blood tests for beta-amyloid and tau proteins D) Blood test for amyloid plaques and neurofibrillary tangles

B) The diagnosis of Alzheimer disease is based on the client history and physical examination. There is currently no one test or procedure that makes the diagnosis of Alzheimer disease. As AD progresses and more neurons die, two characteristic abnormalities develop in the brains of affected individuals. The first is thick protein clots called neurofibrillary tangles, and the second is insoluble deposits known as amyloid plaques, but these changes are found at autopsy, not by a CT scan or blood test.

8) The staff on a care area that has a high percentage of clients with confusion attends an educational program on delirium management. Which statement, made by a staff nurse, indicates that teaching has been effective? A) "It is important to provide education for family members as needed." B) "Sensory deprivation and overstimulation can worsen the symptoms the client exhibits." C) "Decreasing all stimulation in the client's room is essential." D) "The family should involve the client in all conversations and interactions involving care."

B) The structure of the client's environment should support cognitive functions. Aids for hearing or vision are necessary to prevent sensory loss or distortion. Familiar objects from home, such as slippers, robe, and photographs, may help with orientation. Easily read clocks, orientation boards, and a structured routine that includes physical activity and socialization without sensory overload will also help with orientation. Clients with delirium can exhibit hyperactivity when overstimulated.

20) Damage to which region of the brain may result in loss of recent memory? A) Neuron B) Hippocampus C) Cerebrum D) Neurotransmitter

B) The structure that plays a role in memory is the hippocampus, located in the limbic system of the brain. A neuron carries and processes information within the nervous system. The cerebrum is the largest region of the brain. A neurotransmitter is a chemical messenger within the nervous system.

16) A nurse is assessing a client diagnosed with Alzheimer disease (AD) in which the family reports that the client recently lost the ability to live independently and is unable to perform certain activities of daily living (ADLs) such as selecting appropriate clothing or preparing meals. The family's report indicates that the client has progressed to which stage of AD? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4

B) This client is in stage 2 (moderate AD) because the client has lost the ability to live independently. In this stage, the client may be unable to choose appropriate clothing or prepare food and is at increased risk of someone taking advantage of him or her because of loss of cognition and lack of safety awareness. A client in stage 1 (mild cognitive impairment) is able to maintain living independently, but the client's memory lapses are apparent to others. In stage 3 (severe AD), individuals become unable to perform even basic activities of daily living (ADLs). AD is described in terms of three stages: stage 1 (early), stage 2 (moderate), and stage 3 (severe).

11) Which clinical manifestation of ADHD is more commonly observed in school-aged girls than in school-aged boys? A) Aggression B) Anxiety C) Sleep disturbances D) Impulsiveness

B) Typically, girls with ADHD show far more anxiety, mood swings, social withdrawal, rejection, and cognitive and language problems than boys, but less aggression and impulsiveness. Sleep disturbances are common in ADHD clients of both genders.

12) A nurse is assessing a child who shows marked abnormalities in speech patterns. These includes using you in place of I, parroting words and phrases, and repeating questions rather than answering them. The nurse should recognize that these are characteristic of which condition? A) Cerebral palsy B) Autism spectrum disorder C) Attention-deficit/hyperactivity disorder (ADHD) D) Failure to thrive

B) Using you in place of I, engaging in echolalia (compulsive parroting of a word of phrase just spoken by another), and repeating questions rather than answering them are speech patterns typically indicative of autism spectrum disorder. Speech abnormalities are generally not seen in cerebral palsy, ADHD, or failure to thrive.

13) A nurse manager is educating a group of staff nurses on recognizing the differences between confusion and delirium. Which statements should be included in the teaching? Select all that apply. A) "Delirium is seen only in older adults." B) "Delirium is a reversible condition while dementia is not." C) "Older adults are at higher risk for developing delirium." D) "Younger adult females are at higher risk for developing delirium." E) "Adolescents are more prone to developing delirium than young children."

B,C Delirium is a reversible condition caused by an acute problem, such as infection, and can occur at any age. Dementia is a cognitive decline generally associated with an aging adult. Older adults are at higher risk for developing delirium, not younger adult females. Also, young children are at greater risk for developing delirium than adolescents because children's bodies are less equipped to cope with insults such as fever, infection, and toxin exposure.

11) The nurse is caring for a school-age client who was admitted with pneumonia and high fever. The parents are very upset because the child is now unable to recognize them. Which statements should the nurse include while educating the parents on their child's symptoms? Select all that apply. A) Reorient the client to time and place as much as possible. B) Encourage the family remain at the bedside as much as possible. C) Explain that high fevers can cause delirium. D) Reassure that the confusion will not last very long. E) Teach the family how to care for the child upon discharge.

B,C The nurse will want to explain that any febrile illness may cause symptoms of delirium and that this symptom will abate when the temperature returns to normal. The presence of parents and family members has been found to reduce the incidence of delirium as well as decrease family stress. Teaching the family how to care for the child during the hospitalization or upon discharge will not necessarily decrease their anxiety. Telling the family the confusion will not last long is not helping them to understand the nature of the symptom.

2) Which should the nurse identify as risk factors for a pregnant client having a baby with autism? Select all that apply. A) Employed as a computer programmer B) Smokes one pack per day of cigarettes C) Drinks two glasses of wine on the weekends D) Age 40 E) Rides a stationary bicycle four times a week for 30 minutes

B,C,D Determining risk for autism is difficult; however, some factors appear to be linked. A maternal age of 40 or older increases the risk that a child will be born with autism. Maternal smoking or the use of alcohol during pregnancy also increases rates of autism. Employment status and exercise level are not risk factors for the development of autism.

11) The nurse plans a class about Alzheimer disease for a caregiver support group. Which should the nurse include when teaching this class of caregivers? Select all that apply. A) Glutamatergic inhibitors are the most common class of drugs for treating Alzheimer disease. B) Alzheimer disease accounts for about 80% of all dementias. C) Chronic inflammation of the brain may be a cause of the disease. D) Depression and aggressive behavior are common with the disease. E) Memory difficulties are an early symptom of the disease.

B,C,D,E Memory difficulties are an early symptom of Alzheimer disease. It is suspected that chronic inflammation and excess free radicals may cause neuron damage, which contributes to the disease. Depression and aggressive behavior are common symptoms of the disease. Alzheimer disease accounts for about 80% of all dementias. The acetylcholinesterase inhibitors, not the glutamatergic inhibitors, are the most widely used class of drugs for treating the disease.

6) The nurse is planning care to address safety needs for an older adult client who has recently been diagnosed with early Alzheimer disease. Which interventions are appropriate to address safety needs? Select all that apply. A) Use of a restraint belt at night to prevent wandering behaviors B) Check shoes for fit and support. C) Contact the department of motor vehicles to have the client's license suspended. D) Keep all familiar objects in the home. E) Remove throw rugs and electrical cords.

B,E All older clients, including those with Alzheimer disease (AD), are at increased risk for injuries such as falls. Shoes should fit and be supportive. Simplifying the home environment while keeping familiar furniture in the same space will reduce confusion and promote safety. Rugs and cords should be removed to prevent falls. The use of physical and pharmacologic restraints should be avoided. In early stages of dementia, clients with Alzheimer disease may continue to drive.

7) The nurse is planning care for a client who is experiencing stage 1 Alzheimer disease. Which intervention will best promote cognitive function? A) Ensure there is background music or sound from the television. B) Dim the lights during waking hours. C) Maintain a daily routine. D) Keep social interaction to a minimum.

C) The client with dementia benefits from a routine schedule of activities, including meal times. The client typically is better oriented when it is quiet. It is important keep the room lit during waking hours; the lights should not be dimmed during this time.

9) The nurse is caring for an adult client with ASD. He indicates that he struggles with finding and maintaining employment. Which action by the nurse best addresses the client's needs? A) Give the client information about state subsidies that will help him get by without a job. B) Suggest the client work for a business owned by a family member or family friend. C) Ask the client what his strengths are and identify types of jobs based on those strengths. D) Encourage the client to seek opportunities that do not require communication with others.

C) Adults with ASD are most successful when they seek employment opportunities that play to their strengths. Many adults with ASD are financially subsidized by the state, but if the client wishes to work, the nurse should encourage him and help him with that goal. Working for a family member or friend's business might help the client find a job, but does not address the issues that make it difficult for him to keep a job. Communication is a struggle with clients with ASD, but discouraging communication with others would not be appropriate, nor is it realistic in the workplace.

9) A community health nurse is educating pregnant clients about the risk factors associated with the development of attention-deficit/hyperactivity disorder (ADHD). Which statement will the nurse include in the educational session? A) "ADHD has not been linked to prenatal exposure or disease." B) "ADHD has been linked to a specific gene, and genetic testing may help to diagnose this." C) "ADHD has been linked to prenatal exposure to cigarette smoke." D) "ADHD has been linked to childhood exposure to folate."

C) Although ADHD has not been linked to a specific gene, the disorder has been linked to prenatal exposure or disease. Prenatal exposure to cigarette smoke increases the risk for the child to develop ADHD. ADHD has been linked to childhood exposure to lead, not folate.

8) The nurse is educating the family and client, who was recently diagnosed with Alzheimer disease (AD), regarding long-term care placement. Which is the rationale for providing this information to the family at this time? A) It often takes 6 to 12 months for an individual with AD to establish a successful transfer to a facility, and this will allow adequate time. B) It's better to address the issue of placement now instead of later. C) Early introduction to long-term options will allow the client and family time to make a more informed decision. D) Long-term care placement is inevitable with this diagnosis.

C) Although placement in a long-term care facility is not going to be the fate of all individuals with Alzheimer disease, it is a common one. Providing the information early in the disease process allows the family to make an informed choice. Nurses will need to provide reinforced education and referrals throughout the disease process, not just during the initial hospitalization. There is no plan to transfer the client at this time; adjustment would occur after the transfer.

2) An older adult client with no history of cognitive impairment is suddenly showing signs of increased confusion and possible delirium. Which health problem should the nurse suspect is causing this client's confusion? A) Cataracts B) Hypertension C) Urinary tract infection D) Lower back strain

C) Delirium is often the most prominent manifestation of conditions such as dehydration, respiratory tract infections, urinary tract infections, and urinary retention, and adverse drug events may occur in the absence of symptoms such as fever or discomfort. Hypertension, lower back strain, and cataracts are not conditions that are known to cause signs of confusion in older adults.

9) The nurse is explaining the difference between delirium and dementia to a family member of a client with confusion. Which statement is appropriate for the nurse to include? A) "The cause of delirium is always unknown." B) "Dementia develops suddenly." C) "Delirium is a serious but common occurrence in older adult clients who are hospitalized." D) "Delirium is often confused with depression in older adult clients."

C) Hospitalized clients are much more likely to experience delirium because of the presence of predisposing illnesses, exposure to multiple medical interventions that may contribute to cognitive changes, and being in an environment that is unfamiliar, stimulating, and not conducive to maintaining normal diurnal rhythms. Delirium is an acute rapid-onset condition with an etiology that can usually be traced to a known cause. The cause of delirium can often be determined, and removal of the cause will usually result in complete recovery. The symptoms of delirium are not similar to those of depression.

10) A client with Alzheimer disease is scheduled to attend occupational therapy three times a week. Which is the purpose of the client attending this type of therapy? A) Improve language deficits B) Improve muscle tone C) Ability to perform activities of daily living D) Improve access to community organizations

C) Individuals who are starting to experience language deficits may be able to slow this decline by working with a speech therapist. Physical therapy can help individuals improve their muscle tone, maintain coordination, and maintain their range of motion. Occupational therapy helps the client maintain the ability to perform many activities of daily living. Access to community organizations is facilitated through the use of social workers.

11) An individual with ASD who demonstrates marked distress on switching activities (such as responding with loud verbalizations and behaviors that could result in self-harm) is demonstrating which level of clinical manifestations of the disorder? A) Level I clinical manifestation B) Level II clinical manifestation C) Level III clinical manifestation D) Level IV clinical manifestation

C) Marked distress on switching activities is a level III manifestation of ASD. Level I manifestations typically include inflexible behavior and organizational problems, and level II manifestations typically involve difficult switching activities but not distress. There is no level IV categorization for clinical manifestations.

8) The nurse is caring for a child diagnosed with autism spectrum disorder (ASD) who is being admitted to the hospital with dehydration. Which action by the nurse is appropriate when the child arrives to the care area? A) Take the child on a tour of the pediatric unit. B) Take the child to the playroom for arts and crafts. C) Quietly orient the child to a single-bed hospital room. D) Orient the child to a four-bed unit.

C) Orienting a child with autism to a new environment is important, although this must be done in a quiet, controlled environment. A single room is the best place for an autistic child if the child must be hospitalized. Taking a child with autism on a tour of the pediatric unit would be too much stimulation for this child. Arts and crafts might be appropriate for an autistic child if done in the child's room, but going to the playroom would be too much stimulation for this child. An autistic child should be in a single room, if possible, away from distractions.

10) Assuming approximately the same birth weight, level of prenatal care, and level of genetic predisposition, which of the following infants is least likely to develop ADHD during childhood? A) An infant born at 35 weeks' gestation B) An infant born at 36 weeks' gestation C) An infant born at 38 weeks' gestation D) An infant born at 34 weeks' gestation

C) Preterm birth is a risk factor for ADHD. The infant born at 38 weeks is considered a term infant; all the others are considered preterm. Thus, the infant born at 38 weeks is at lowest risk.

12) The nurse is reviewing pharmacologic treatments with a caregiver of an individual with Alzheimer disease. Which statement indicates that teaching has been effective? A) "There are effective drugs, but they cannot be used over a long period." B) "There aren't any drugs that are effective in treating this disease." C) "The earlier the drugs are started, the greater the likelihood they will have benefits." D) "There are drugs that can control symptoms for many years."

C) The earlier the medications are started, the greater the effect they will have on the symptoms of Alzheimer disease. Current medications will only decrease symptoms for a short period of time. Drugs will not control symptoms for many years. The drugs for treatment of Alzheimer disease are no more dangerous than other drugs used for a long period of time.

8) The nurse is caring for a client with perceptual disturbances who is becoming agitated. Which action should the nurse take first? A) Distract client by taking into the dayroom to watch television with other clients. B) Administer medications to sedate client before violent behaviors occur. C) Request client to go back to room and dim lights. D) Do nothing, as this is a normal manifestation of disturbed cognition.

C) The nurse that observes a client demonstrating visual disturbances and/or psychotic behaviors should intervene by decreasing the environmental stimulus. If overstimulated, the client with visual disturbances or psychosis may display agitation. The use of physical and pharmacologic restraints should be avoided. Taking the client into the dayroom to watch television with others may overstimulate the client, further increasing agitation, which may increase risk of violence toward others.

7) A hospitalized older adult client suddenly does not recognize an adult daughter and states, "Why hasn't my wife come to see me?" The client's spouse has been deceased for 5 years. Prior to the hospitalization, the client was oriented to person, place, time, and reality. Which nursing diagnoses would be appropriate for this client? Select all that apply. A) Risk for Autonomic Dysreflexia B) Anxiety C) Acute Confusion D) Risk for Injury E) Ineffective Coping

C,D The client is experiencing acute confusion and is also at risk for injury according to the scenario presented. The scenario does not indicate the client is experiencing anxiety or ineffective coping. Autonomic dysreflexia is a syndrome of clients with spinal cord damage, which is not indicated for this client.

4) A nurse is caring for a school-age client who is scheduled to have a tonsillectomy the next day. The nurse has planned a preoperative teaching session for the child, who has a history of attention-deficit/hyperactivity disorder (ADHD). Which teaching technique is most appropriate for this client? A) Play a video describing the procedure to the child. B) Ask other children who have had this procedure to talk to the child. C) Allow the child to lead the teaching session to gain a sense of control. D) Give instructions verbally and use a picture pamphlet, repeating points more than once.

D) A teaching session for a child with ADHD should foster attention. Giving instructions verbally and in written form, repeating the main points, will improve learning for a child with ADHD. Talking to other children who have had this procedure may not foster understanding, because this child has ADHD. The nurse, not the client, should lead the teaching session to make sure it progresses appropriately and covers all necessary information. A video is not appropriate for this client because it may foster distraction, and also because it does not permit the client to ask questions until the program has concluded. Given this client's history of ADHD, it is unlikely that he or she will remember all such questions until the end of the video.

6) The nurse is teaching the family of a child who is prescribed amphetamine mixed salts sustained release (Adderall XR) for attention-deficit/hyperactivity disorder (ADHD). Which of the following should the nurse teach the family is the besttime to administer the medication? A) Just before lunch B) At bedtime C) With the evening meal D) Early in the morning

D) Administering the medication early in the day can help alleviate the effect of insomnia. Before lunch might be difficult and cause embarrassment to the child if the child is in school. Evening and bedtime are incorrect as this medicine can cause insomnia.

12) A nurse is completing a psychosocial assessment of an adult client. Which finding is most consistent with an adult who has ADHD? A) "The client stated that he has many friends and an active social life, and he thrives in fast-paced environments." B) "The client stated that at times he feels tired and listless, struggling to get out of bed and complete basic self-care tasks." C) "The client stated that he feels confident when completing job tasks and is punctual and effective at work, even though he has difficulty getting along with coworkers." D) "The client stated that he struggles with alcohol use and often engages in unprotected sex and recreational drug use."

D) Chemical dependence and participation in risky behaviors are common in adults with ADHD. Personal and social relationships tend to be difficult for adults with ADHD, so it is unlikely he would enjoy socializing with others. In addition, adults with ADHD tend to struggle in the workplace. Finally, tiredness, listlessness, and inability to complete care tasks would be indicative of depression, not ADHD.

3) A client diagnosed with Alzheimer disease becomes agitated during an activity involving simultaneous music playing and a craft project. The client starts shouting, "No! No! No!" and runs from the room. Which action by the nurse is the most appropriate? A) Administer a prn anti-anxiety medication. B) Restrict participation in any group activities. C) Call security and prepare physical restraints. D) Reassure the client and then redirect to a quiet area.

D) Environmental stimuli should be kept at a minimum for clients with dementia. A quiet environment will prevent sensory overload. Once the client is less agitated, the client can be directed to a less stimulating activity. Use of physical and pharmacologic restraints should be avoided.

6) The healthcare provider prescribes aripiprazole (Abilify) for the client with schizophrenia. Which is the priority outcome for the client? A) The client will report a decrease in auditory hallucinations. B) The client will report symptoms of restlessness. C) The client will consume adequate fluids and a high-fiber diet. D) The client will adhere to the medication regime.

D) Medication compliance is a priority for clients with schizophrenia. Relapse of symptoms will occur without the medications. The symptom of restlessness is known as akathisia. This would be important to report, but it is not the priority outcome. Adequate fluids and fiber will decrease the side effect of constipation, but this is not the priority outcome. A decrease in auditory hallucinations is an expected effect of aripiprazole (Abilify), but this is not the priority outcome.

5) The parent of a child with autism spectrum disorder (ASD) asks why family therapy has been prescribed. Which response by the nurse is most appropriate? A) "Family therapy will help you learn how to assess your child's potential." B) "Family therapy will provide your child with an opportunity to learn problem-solving skills." C) "Family therapy will help you interact with your child." D) "Family therapy will help you learn how to cope with your child's diagnosis."

D) Parents of children with autism report more family problems, more marital problems, more depression, and more social isolation than parents of typically developing children or parents of children who are severely and persistently mentally ill. Family therapy will help them cope with the diagnosis through the problem-solving process. The other responses are important interventions for the child but are not the goal of family therapy.

2) The nurse is interviewing the mother of a child who is being evaluated for attention-deficit/hyperactivity disorder (ADHD). When assessing the child's health history, which of the following should the nurse identify as a risk factor for ADHD? A) The measles, mumps, and rubella (MMR) vaccine B) The immune response of the child C) Young parental age at conception D) Smoking during pregnancy

D) Research shows that a mother's use of cigarettes during pregnancy can increase the risk for ADHD. Immune response can be associated with autism spectrum disorders but not ADHD. Young parental age has not been associated with ADHD. The measles, mumps, and rubella vaccine was once thought to be associated with autism spectrum disorder, not ADHD, but multiple studies have found no link between immunizations and autism.

1) The spouse of a client with Alzheimer disease does not understand why the client developed the disorder because no one else in the family has the health problem. Which response by the nurse is appropriate? A) "Alzheimer disease develops because of smoking and alcohol intake." B) "Someone in your family must not have been correctly diagnosed with the disorder." C) "Alzheimer disease does not have the same course in every individual." D) "There are genetic and environmental factors in the development of Alzheimer disease."

D) Researchers are not sure why most cases of Alzheimer disease (AD) arise, although a variety of genetic and environmental factors appear to be involved. Alzheimer disease is not directly linked to smoking and alcohol intake. It is inappropriate to assume that other family members had the disorder but were misdiagnosed. Alzheimer disease has a predictable course with distinct phases or stages.

12) Which is true regarding the Confusion Assessment Method (CAM)? A) It consists of five parts and is a lengthy test. B) It measures the severity of the client's delirium. C) It is also effective in screening for depression. D) It is effective in screening for cognitive impairment and reversible confusion.

D) The Confusion Assessment Method (CAM) is a tool the nurse can use to differentiate between delirium and dementia. It consists of two parts; the first part screens for cognitive impairment and the second part screens for reversible confusion. Although it is effective in differentiating between delirium and dementia, it does not measure the severity of the client's delirium and it does not screen for depression.

4) The parents of a child with autism spectrum disorder (ASD) observe that the child has difficulty making friends and are concerned about social expectations for their child. Which of the following is the priority diagnosis for this child based on the parents' concern? A) Ineffective Coping B) Deficient Diversional Activity C) Social Isolation D) Impaired Social Interaction

D) The parents want to know what the social expectations for their child are. ASD involves difficulties in the quality of both the social interactions and the communication of the child. In social interactions, the child may have problems making eye contact, developing appropriate peer relationships, and spontaneously seeking out shared enjoyment with other people, or the child may show no social or emotional reciprocity. When overaroused by sensations (internal or external), the individual with ASD reacts as if the stimulus is irritating or even threatening. Children with ASD may shut down or try to get away from the stimulus by screaming, covering their ears, or running away. Often they are overly sensitive to sounds, tastes, smells, and sights, may prefer soft clothing and certain foods, and may be bothered by sounds or sights no one else hears or sees. At other times, they may be oblivious to what is occurring in the environment. The parents did not ask about social isolation and diversional activity. The parents do not indicate that the child is struggling to cope with these issues.

17) The nurse is educating a client who is diagnosed with stage 1 Alzheimer disease (AD) and the client's spouse. Which suggestion best promotes maintaining functional ability at this stage? A) Obtain round-the-clock care at home B) Prepare liquid nutrition C) Assist client with ADLs D) Begin making "to-do" lists and use of a calendar

D) Use of cuing devices such as to-do lists, calendars, written schedules, and verbal reminders can aid in maintaining client's highest level of functioning. The other options are interventions for a client diagnosed with stage 3 AD.

15) Which is true regarding the pathophysiology and etiology of Alzheimer disease? Select all that apply. A) Damage to the limbic system results in speech decline and slowed movements. B) Familial Alzheimer disease (eFAD) is also called delayed-onset Alzheimer disease. C) Sporadic Alzheimer disease usually manifests before age 65. D) Sporadic Alzheimer disease is more common than familial Alzheimer disease. E) In Alzheimer disease, neuronal cells die in a characteristic order.

D,E In Alzheimer disease, the neuronal cells die in a characteristic order, beginning with neurons in the limbic system, including the hippocampus. There are two basic types of AD: familial and sporadic. Familial AD (eFAD) has a strong inherited component and is also called early-onset AD because it usually manifests before age 65. Sporadic AD shows no clear pattern of inheritance, although genetic factors may be involved. Because it typically develops after age 65, sporadic AD is sometimes referred to as late-onset AD. Damage to the limbic system from AD results in memory loss and emotional problems.