craven chapter 37
A nurse is assessing a client who has developed altered cognition secondary to an infection. The nurse understands that which type of infection is a common cause? Select all that apply. - Urinary tract - Respiratory system - Wound - Gastrointestinal tract - Nervous system
Urinary tract Respiratory system Wound Nervous system
A nurse is discussing factors that can affect cognitive function with a group of older adults at the local senior center. The nurse explains that a person's perceptual ability declines with aging due to: -diminished sense organ function. - physical discomfort. - emotional stress. - pain.
diminished sense organ funciton
The nurse is caring for a client who has had a stroke. Since the stroke, the client has trouble saying words correctly and his speech seems slurred. The nurse documents this speech pattern as: A)expressive aphasia. B)anomic aphasia. C)dysphasia. D)dysarthria
dysarthria
The thinking patterns of a 4-year-old will typically demonstrate A)Categorization B)Abstract thought C)Conservatism D)Egocentrism
egocentrism
The nurse is providing care to a client who has suffered a stroke. The client is attempting to speak but his speech is very slow and monotone, consisting of small groups of words. The nurse would identify this as which type of aphasia? -Receptive -Global -Expressive -Anomic
expressive
A nurse is providing care to a client with dysarthria. Which action would be most appropriate for the nurse to do? -Face the client to read his lips. -Limit the use of gestures when talking. -Encourage the client to speak quickly and quietly. - Provide environmental cues.
face the client to read his lips
The nurse is caring for a client who has suffered a stroke. The client is now unable to speak, read, or write. She is also unable to understand spoken language. The nurse would document this as: A)anomic aphasia. B)expressive aphasia. C)receptive aphasia. D)global aphasia.
global aphasia
For optimal functioning, the brain requires a large amount of A)Sodium B)Magnesium C)Glucose D)Vitamin A
glucose
A nurse is developing a plan of care for a client with dysarthria. Which of the following would be a priority intervention? -offering the client thin liquids -having the client fully upright when eating -providing nutrition via tube feedings - referring the client to physical therapy
having the client fully upright when eating
Which step would the nurse take first to identify delirium when caring for clients who are at risk? -Know the client's baseline cognitive status. - Identify the cause of the delirium. -Review the client's medications. - Reorient the client.
know the clients baseline cognitive status
A nurse is assessing a client who has experienced a stroke for indications of problems with communication. On observation, the nurse notes that the client is laughing one minute and then suddenly begins to cry. The nurse would document the client's affect as: - normal. - flat. -labile. -blunted.
labile
A nurse is assessing a client who has experienced a stroke for indications of problems with communication. On observation, the nurse notes that the client is laughing one minute and then suddenly begins to cry. The nurse would document the client's affect as: - normal. -flat. - labile. - blunted.
labile
A nurse is assessing a client who has experienced a stroke for indications of problems with communication. On observation, the nurse notes that the client is laughing one minute and then suddenly begins to cry. The nurse would document the client's affect as: -normal. - flat. - labile. - blunted.
labile
A nurse is providing care to a client who has C2, C3 quadriplegia and a permanent tracheostomy. The client cannot speak. The nurse understands that this inability to speak is most likely the result of: -loss of functions of the muscles. - inadequacy of blood flow to the speech area in the brain. -bacterial infection of the brain cells. - lack of air forcing through the vocal cords.
lack of air forcing through the vocal cords
A client is diagnosed with late stage Alzheimer's disease. The client is being cared for at home with the help of his son, the son's family, and home care services. The son tells the home care nurse, "We're just so tired. Caring for my father is really tough." Which suggestion would be most appropriate for the son and his family at this time. -"I think it's time for your father to be moved to a long-term care setting." - "Let's talk about possibly getting you and your family some respite care." - "Maybe your father would benefit from more home health care services." -"How about we try some music therapy to help calm him."
lets talk about possibly getting you and your family some respite care
A nurse is providing care to a client with an impairment in cognitive function. Which recommendation would be most appropriate to include in the client's plan of care? Select all that apply. -maintaining a structured environment - minimizing distractions - removing environmental cues - providing frequent reminders - firmly telling the client that he is wrong
maintaining a structured environment minimizing distractions providing frequent reminders
The ear consists of the external ear, the tympanic membrane, the middle ear, and the inner ear. Which of the following is found in the middle ear? Select all that apply. - Malleus -Cochlea -Incus -Stapes - Labyrinth
malleus incus stapes
After presenting a seminar on cognitive function, one of the participants asks the nurse, "What really is intelligence?" The nurse would integrate knowledge of which concepts when responding? Select all that apply. - Memory - Reality - Concentration - orientation -Judgment - Comprehension
memory comprehension concentration
A client with mild memory impairment is being discharged home to be cared for by his family. When educating the family about caring for the client, which aspect would the nurse emphasize? -need for a predictable environment -strict avoidance of the use of aids such as lists -importance of stimulating the client with frequent new experiences -need to adhere to treatment plan by speech therapy
need for a predictable environment
The nurse is caring for a client who is difficult to arouse and when aroused is confused. The nurse would document the client's condition as: A)lethargic. B)obtunded. C)somnolent. D)depressed.
obtunded
Which term is used to describe a person's level of arousal? - Delirium - Sundown syndrome - Aphasic -Obtunded
obtunded
Which term is used to describe a person's level of arousal? -Delirium -Sundown syndrome -Aphasic -Obtunded
obtunded
As part of a presentation on cognition, a nurse is planning to discuss the concept of consciousness and how the nervous system is involved. Which structure would the nurse identify as being responsible for mediating the level of arousal? - Cerebral cortex - Reticular activating system - Sensory receptors -Neurotransmission
reticular activating system
As part of a presentation on cognition, a nurse is planning to discuss the concept of consciousness and how the nervous system is involved. Which structure would the nurse identify as being responsible for mediating the level of arousal? -Cerebral cortex -Reticular activating system - Sensory receptors - Neurotransmission
reticular activating system
As part of a presentation on cognition, a nurse is planning to discuss the concept of consciousness and how the nervous system is involved. Which structure would the nurse identify as being responsible for mediating the level of arousal? -Cerebral cortex -Reticular activating system - Sensory receptors -Neurotransmission
reticular activating system
A nurse is developing an in-service education program for a group of nursing assistants. The nurse is planning a discussion on ways to help promote reality orientation for clients experiencing cognitive deficits. Which of the following would the nurse be least likely to include in the discussion? -Placing clocks and calendars in the clients' rooms. - Making sure the lighting matches the time and place -Rotating caregivers to prevent staff stress and burnout Allowing for periods of uninterrupted sleep when possible.
rotating caregivers to prevent staff stress and burnout
A nurse is reviewing the diagnostic test results of a client with acute confusion. Which would the nurse identify as possibly contributing to the client's acute confusion? - oxygen saturation of 93% -serum sodium level of 128 mEq/L -serum calcium level of 9.1 mg/dL -blood glucose level of 88 mg/dL
serum sodium level of 128 mEq/L
A nurse is reviewing the diagnostic test results of a client with acute confusion. Which would the nurse identify as possibly contributing to the client's acute confusion? -oxygen saturation of 93% - serum sodium level of 128 mEq/L -serum calcium level of 9.1 mg/dL - blood glucose level of 88 mg/dL
serum sodium level of 128 mEq/L
A nurse is engaging in therapeutic communication with a client who has chronic confusion. Which action would be most appropriate for the nurse to do? -Sit at eye level with the client. - Use a loud, strong tone of voice - Frequently ask the client "Why" questions. - Try to persuade the client with logic.
sit at eye level with the client
The toddler begins to label familiar items such as 'the stove is hot', and 'the ball bounces' at age A)Less than one B)1 to 3 years C)3 to 5 years D)5 to 7 years
1 to 3 years
A nurse is working at a well-child clinic. Which client would the nurse most likely identify as being capable of abstract thinking? -3-year-old -7-year-old -12-year-old -15-year-old
15 year old
A nurse is assessing a client's mental status using the Mini-Mental State Examination. Which score would lead the nurse to suspect that the client is experiencing significant cognitive impairment? -30 - 27 -21 -18
18
A client comes to the clinic for an examination. During the visit, the nurse evaluates the client's cognitive function using the Mini-Mental State Examination. On previous visits, the client's score was 28. The nurse determines that the client is experiencing a significant decline in his cognitive function based on which score? -26 - 24 -22 -20
20
A client who was previously alert and oriented is becoming confused. The nurse checks his oxygen saturation level. Which level would the nurse identify as possibly contributing to the client's confusion? -97% - 94% -92% -89%
89%
Which of the following types of aphasia occurs in the brain-injured person and results in limited speech that is slow and halting, is completed with great effort, and is poorly articulated? A)Anomic B)Receptive C)Global D)Broca's
Broca's
A nurse is assessing a client's cognitive function. The nurse would assess which of the following first? -Consciousness -Attention -Language use - Memory
consciousness
A client with liver failure is confused and disoriented. The nurse understands that a buildup of which substance may be responsible for his current status? -Calcium -Ammonia -Glucose -Urea
ammonia
A client is brought in for evaluation because his family thinks that he may be developing Alzheimer's disease. When obtaining the history, which statement by the family would the nurse identify as supporting this condition? Select all that apply. -"He really has problems remembering simple things, like where the bathroom is." -"He gets really agitated in the late afternoon and early evenings for no reason at all." - "He often wakes up at night and doesn't know where he is." -"He's been falling quite a bit lately, like his legs don't want to work." -"He has been having problems controlling when he urinates, often soiling his clothes.
"He really has problems remembering simple things, like where the bathroom is." "He gets really agitated in the late afternoon and early evenings for no reason at all." "He often wakes up at night and doesn't know where he is."
A nurse is working at a community health center that provides care to middle-age and older adults. A client at the center asks the nurse about what she can do to "keep her brain functioning at its best." Which response by the nurse would be most appropriate? Select all that apply. -"Try eating a balanced diet with adequate protein, iron and other nutrients." -"Be sure to limit the amount of water you drink each day along with your salt intake." -"Engage in nonaerobic activity whenever possible." - "Participate in moderately intense activity, about an hour per day, 3 times a week." -"Make sure to follow any prescribed regimen if you have any health conditions."
"Try eating a balanced diet with adequate protein, iron and other nutrients." "Participate in moderately intense activity, about an hour per day, 3 times a week." "Make sure to follow any prescribed regimen if you have any health conditions."
The nurse suspects that a client with delirium is most likely experiencing a neurologic emergency based on which assessment finding? Select all that apply. -Facial drooping - Pronator drift - Ataxia -Diminished sense of smell - Pain
Facial drooping Pronator drift Ataxia
Which of the following problems is the most likely physical cause of an elderly client's altered cognition? A)Hyperthyroidism B)Hypothyroidism C)Hypopituitarism D)Hyperparathyroidism
Hypothyroidism
When a nurse makes a home visit and finds that a previously alert and oriented elderly client is demonstrating early signs of confusion, the nurse suspects that the client may be experiencing the onset of A)Hyperglycemia B)Infection C)Hepatic encephalopathy D)Hyperkalemia
Infection
A nurse is assessing a client's cognitive function. The nurse would assess which of the following first? - Attention - Language use -Consciousness -Memory
consciousness
A nurse is preparing an in-service presentation about impaired thought processes. When describing delirium, which of the following would the nurse explain as a common cause? Select all that apply. -Medications -Metabolic disorders - Sensory deprivation -Overstimulation -Reduced stress threshold
Medications Metabolic disorders
A nurse is caring for a client with schizophrenia. The nurse understands that patients suffering from schizophrenia have problems in which of the following areas? Select all that apply. A)Processing information B)Inappropriate social behavior C)Communication D)Memory E)Decision making
Processing information Inappropriate social behavior Communication Memory Decision making
A nurse is providing care to a client who is confused. The nurse is reviewing the client's laboratory test results. Which finding would the nurse identify as a possible contributing factor to the client's confusion? -Total serum calcium level 14.2 mg/dL - Serum sodium level 140 mEq/L -Serum glucose level 82 mg/dL - Serum potassium level 4.1 mEq/L
Total serum calcium level 14.2 mg/dL
Which statement is true regarding dementia? -It is the rapid decline in all cognitive processes. - It is a normal process of aging. -It is a progressive impairment of intellectual function and memory. - It is associated with disturbance in level of consciousness (LOC).
Which statement is true regarding dementia?
The nurse assesses a client and suspects that the client may be experiencing hypoactive delirium. Which finding would support this suspicion? Select all that apply. -Withdrawn behavior -Lethargy - Sedated appearance - Agitation -Disruptive behavior
Withdrawn behavior Lethargy Sedated appearance
A nurse is preparing a presentation for a group of new nurses about the perception of information. As part of the presentation, the nurse plans to talk about how touch and pressure are transmitted. Place the steps below in the correct order that depicts the transmission. -impulse traveling through to the parietal lobe -impulse traveling through the spinal cord -activation of somatic skin sensors -impulse traveling through the thalamus
activation of somatic skin sensors impulse traveling through the spinal cord impulse traveling through the thalamus impulse traveling through to the parietal lobe
After teaching a class about developmental aspects related to cognition, the instructor determines that the education was successful when the class identifies serialization as developing during which developmental stage? -Preschool age - Adolescence -Young adulthood - Old age
adolescence
A nurse is caring for a client who had difficulty finding the correct names for particular objects. The nurse would document this as: A)anomic aphasia. B)receptive aphasia. C)expressive aphasia. D)global aphasia.
anomic aphasia
A nurse is concentrating on a specific task without being distracted by other things in the environment. The nurse is demonstrating: -attending. - perceiving. - thinking. - learning.
attending
A nurse is developing an education plan for the family of a client with dementia and plans to describe normal cognitive processes, including how these processes are affected by the client's condition. Which term would the nurse use to describe the ability to concentrate and take in specific stimuli? -Learning -Memory -Attention -Communication
attention
A nurse is developing an education plan for the family of a client with dementia and plans to describe normal cognitive processes, including how these processes are affected by the client's condition. Which term would the nurse use to describe the ability to concentrate and take in specific stimuli? -Attention -Learning -Memory -Communication
attention
The nurse recognizes that the client diagnosed with global aphasia will A)Have difficulty with grammar and articulation B)Demonstrate unintelligible speech C)Express comments that do not make sense D)Be unable to speak, read, or write
be unable to speak read or write
A nurse is assessing a client and finds that the client has deficits involving speech and forming words. Which area would the nurse most likely identify as being affected? - Wernicke area -Temporal lobes -Broca area -Parietal lobes
broca area
A nurse is assessing a client who is experiencing significant impairment of his long-term memory. The nurse understands that this is most likely due to: - situational stress. - emotional stress. -central nervous system disorder. -electrolyte imbalance.
central nervous system disorder
A nurse is assessing a client who is experiencing significant impairment of his long-term memory. The nurse understands that this is most likely due to: -situational stress. - emotional stress. -central nervous system disorder. -electrolyte imbalance.
central nervous system disorder
A nurse is preparing a presentation on cognition for a group at a local senior center. As part of the presentation, the nurse is planning to discuss how thought, memory, consciousness, learning, and communication are coordinated. Which structure would the nurse describe as responsible for this coordination? -Cerebral cortex - Spinal cord -Cerebellum -Sensory receptors
cerebral cortex
The most appropriate diagnosis for the elderly client with Alzheimer's disease who requires bathing is A)Chronic confusion related to dementia and biochemical imbalances as evidenced by hallucination B)Chronic confusion related to disease process as evidenced by the inability to manage activities of daily living C)Altered thought processes related to confusion, biochemical imbalances, and Alzheimer's disease D)Confusion as evidenced by inability to remain oriented to place and time resulting from Alzheimer's disease
chronic confusion related to disease process as evidenced by the inability to manage activities of daily living
When the elderly client seems very forgetful and often fails to dress appropriately, the nurse determines that the client is demonstrating A)Normal aging B)Confusion C)Cognitive impairment D)Chronic senile dementia
cognitive impairment
A nurse is describing the concept of memory to a group of older adults at a community center. When describing how long-term memory develops, the nurse integrates knowledge of which structure as playing a role? - Reticular activating system -Cerebral cortex -Proprioceptors -Hippocampi
hippocampi
A nurse is providing care to a client who is experiencing an altered level of arousal. While observing the client, the nurse notes that the client becomes startled at an unexpected noise. The nurse documents this level of arousal as: -alert. - lethargic. -hypervigilant. -obtunded.
hypervigilant
A nurse is providing care to a client who is experiencing an altered level of arousal. While observing the client, the nurse notes that the client becomes startled at an unexpected noise. The nurse documents this level of arousal as: -hypervigilant. -alert. - lethargic. -obtunded.
hypervigilant
Assessment reveals that a client is acutely aware of the environment and startled by unexpected noises. The nurse would document this as: -hypervigilant. -lethargy. -alertness. -obtunded.
hypervigilant
Assessment of a client reveals that he has a reduced serum potassium level that is contributing to cellular dysfunction resulting in cognitive changes. The nurse would document the client's reduced serum potassium level as: -hypoglycemia. -hyponatremia. -hypocalcemia. -hypokalemia.
hypokalemia
A nursing instructor is describing how a person perceives information and the role of exteroceptors, proprioceptors, and interoceptors. Which of the following would the instructor include as the location of proprioceptors? Select all that apply. -Rods and cones -Hair cells in the Organ of Corti -Taste buds - Inner ear - Muscles - Joints
inner ear muscles joints
A group of nursing students is developing plans of care for assigned clients with cognitive problems based on their understanding of cognition. The students demonstrate a sound knowledge base when they integrate which statement into the plans of care? -Memory means the ability to grasp the meaning of stimuli. - Intelligence is an abstract characteristic that is non-measurable. -Comprehension means the ability to filter extraneous stimuli to focus on a task. -Intelligence consists of memory, comprehension, and concentration.
intelligence consists of memory, comprehension, and concentration
Sensory receptors that respond to stimuli from deeper tissues such as bone are termed A)Neuroreceptors B)Interoceptors C)Proprioceptors D)Exteroceptors
interoceptors
Which statement is true regarding dementia? - It is the rapid decline in all cognitive processes. - It is a normal process of aging. -It is a progressive impairment of intellectual function and memory. - It is associated with disturbance in level of consciousness (LOC).
it is progressive impairment of intellectual function and memory
A group of nursing students is reviewing information about cognition. One of the students gives the following example: A driver sees a truck blocking the road ahead and decides to stop his vehicle. The student then asks the other students which characteristic of normal cognition the driver is demonstrating. The students demonstrate understanding of the information when they identify the characteristic as: -orientation. -recall. -judgment. - recognition.
judgment
A nurse sees a client walking slowly down the hall. The client is swaying to one side and is observed grabbing onto a chair that is nearby. The nurse determines that the client is about to fall and takes action to prevent it. The nurse is demonstrating which characteristic of normal cognition? -Judgment -Recall -Reality orientation -Intelligence
judgment
After teaching a class on normal cognitive function, the instructor determines that the teaching was successful when the class identifies which structure as being important to auditory sensation and meaningful sound. - Reticular activiating system - Organ of Corti -Spinothalamic tract -Retina
organ of corti
After teaching a class on normal cognitive function, the instructor determines that the teaching was successful when the class identifies which structure as being important to auditory sensation and meaningful sound. -Reticular activiating system -Organ of Corti -Spinothalamic tract - Retina
organ of corti
A nurse is reviewing the past medical history of a client diagnosed with Lewy Body Dementia (LBD). Which condition would the nurse expect to find? - Stroke -Parkinson's disease - Depression -Multiple sclerosis
parkinsons disease
A nurse is reviewing the past medical history of a client diagnosed with Lewy Body Dementia (LBD). Which condition would the nurse expect to find? -Stroke - Parkinson's disease -Depression -Multiple sclerosis
parkinsons disease
A nursing instructor is describing normal cognitive patterns. Which term would the instructor use to describe the receiving and interpreting of sensory stimuli that function as a basis for understanding, knowing, or learning? -Attending -Perceiving - Thinking -Learning
perceiving
The process of receiving and interpreting the sensory stimuli that functions as a basis for understanding, knowing, and learning is termed A)Memory B)Attending C)Thinking D)Perception
perception
The nurse is caring for a patient with altered cognitive function who has recently been admitted to the hospital from a long-term care facility. Which of the following interventions would address the client's safety? Select all that apply. A)Place the client in a room close to the nurses' station. B)Keep the bed in the lowest position possible. C)Use a night light in the patient's room. D)Keep the patient's door closed to reduce noise. E)Leave the television on at all times.
place the client in a room close to the nurses station keep the bed in the lowest position possible use a night light in the patients room
A group of nursing students is reviewing information about normal cognitive function. The students demonstrate understanding of the information when they identify which structure as being important to wakefulness and cardiovascular reflexes? -Reticular activating system -Organ of Corti -Cochlea -Retina
reticular activating system
Sensory receptors that are located in the ear, muscles, tendons, and joints that relate to the body's physical state are termed A)Neuroreceptors B)Interoceptors C)Proprioceptors D)Exteroceptors
proprioceptors
After presenting an in-service program on cognition and normal cognitive patterns to a group of new nurses, the nurse determines that the education was successful when the group identifies which process as following a logical thought sequence? - Thinking -Reasoning - Learning - Perceiving
reasoning
After presenting an in-service program on cognition and normal cognitive patterns to a group of new nurses, the nurse determines that the education was successful when the group identifies which process as following a logical thought sequence? -Thinking - Reasoning -Learning -Perceiving
reasoning
While caring for a client, the client says, "See this rose my son sent me. It is such a beautiful flower." The nurse interprets this statement as indicating which characteristic of normal cognition? -Recall - Recognition -Language - Judgment - Orientation
recognition
The nurse is caring for a client recently diagnosed with Alzheimer's dementia. Which assessment finding would cause the client to question this diagnosis? A)Inattention to ADLs B)Short term memory loss C)Increased agitation at sundown D)Sudden onset of confusion
sudden onset of confusion
When an elderly client is alert and calm during the day but becomes confused and agitated every night, the nurse recognizes that the client is experiencing A)Hallucinations B)Delirium C)Sundown syndrome D)Delusions
sundown syndrome
A nurse is assessing a client and suspects that the client is experiencing disturbed thought processes. Which finding would support the nurse's suspicion? Select all that apply. -Talking to one's self -Withdrawal from others -Deficient attention span -High excitability - Hallucinations
talking to ones self hallucinations withdrawal from others
A nurse is developing a plan of care for a client diagnosed with schizophrenia. The nurse develops interventions based on the understanding that: -the brain shows a decrease in the neurotransmitter dopamine. - there is an increase in the number of dopamine receptors in the brain. -there is an increase in confusion and agitation at the end of the day. -the client shows distortion of reality and difficulty processing information.
the client shows distortion of reality and difficulty processing information
The nurse identifies the nursing diagnosis of Acute Confusion related to medications and dehydration. Which outcome would be most appropriate for this client? -The client will demonstrate functioning at the maximum cognitive level. -The client will demonstrate a return to baseline cognitive status. -The client will participate in activities of daily living. -The client will use effective communication techniques.
the client will demonstrate a return to baseline cognitive status
An 87-year-old woman has just moved into a nursing home after being in an independent retirement facility. Since the move, she has been experiencing a progressive decline in her cognitive functioning. Her room is located across from a nursing station so that she can be observed at all times. Her daughter continues to visit every day for breakfast and has noticed that her mother is showing signs of depression. Since moving, she has become increasingly confused. Which factor is not contributing to this increase in confusion? -The client is in an unfamiliar environment. - The client's room is close to the nursing station. -The client is most likely depressed. -The client's daughter continues to visit at the same time each day.
the clients daughter continues to visit at the same time each day
Which is not true regarding proprioceptors? -They are located in the inner ear. -They are located in tendons. -They sense the relative position of different body parts. -They sense pressure in the skin.
they sense the relative position of different body parts
A nurse is providing care to a client who has a history of stroke. The nurse understands that this client is at risk for which type of dementia? -Alzheimer's disease - Vascular dementia - Frontotemporal dementia - Lewy body dementia
vascular dementia
A nurse is providing care to a client who has a history of stroke. The nurse understands that this client is at risk for which type of dementia? -Alzheimer's disease -Vascular dementia - Frontotemporal dementia -Lewy body dementia
vascular dementia
A nurse is providing care to a client who has a history of stroke. The nurse understands that this client is at risk for which type of dementia? -Alzheimer's disease -Vascular dementia -Frontotemporal dementia -Lewy body dementia
vascular dementia
