MS Exam 3

The nurse is assessing an adult patient during a scheduled health maintenance visit. The patient states, "I have become so forgetful. I am worried that I am developing Alzheimer's disease like my parent did." Which assessment question will help to determine if the patient has memory loss related to Alzheimer's disease (AD)? 1 "Do you sometimes misplace your keys?" 2 "Have you ever forgotten what an item is used for?" 3 "When driving, do you momentarily forget where to turn?" 4 "Do you occasionally have to search for the words that you want to use in a conversation?".

"Have you ever forgotten what an item is used for?" One behavior that is associated with memory loss with AD is forgetting what an item is used for. This question will help the nurse determine if the patient has symptoms of AD. Questions about misplaced keys, searching for words, and momentary lapses while driving help to determine normal forgetfulness

The nurse provides teaching about prescribed medications to a patient who is diagnosed with Alzheimer's disease (AD). Which statement made by the patient indicates the need for further teaching? 1 "I will take zolpidem to help me sleep." 2 "I will take trazodone if I become agitated." 3 "I am taking donepezil to treat problems with my memory." 4 "I am taking fluoxetine for the depression that I have been experiencing since my diagnosis."

"I will take trazodone if I become agitated." Trazodone, an atypical antidepressant, is prescribed for depression associated with the diagnosis of AD, not for agitation. Zolpidem is prescribed for insomnia. Donepezil is prescribed for decreased memory and cognition. These statements indicate appropriate understanding of the medication teaching. Fluoxetine is prescribed for depression.

The nurse provides education to an adult patient who is diagnosed with early-onset Alzheimer's disease (AD). Which statement is appropriate for the nurse to include in the teaching session? 1 "With proper treatment your AD will not advance for 10 years." 2 "The type of AD with which you are diagnosed is the most common form of AD." 3 "Your children should consider genetic testing to determine their risk for AD." 4 "Any family member that tests positive for ApoE-4 will develop AD within five years."

"Your children should consider genetic testing to determine their risk for AD." Patients who are diagnosed with early onset AD should encourage their adult children to be genetically tested for the disease process. The children of any patient diagnosed with early onset AD have a 50% risk for AD. Early onset AD is rare and it is often associated with a more rapid disease course. While proper treatment may slow the progression of AD it will continue to advance and is fatal. Most patients die from AD within 4 to 8 years of diagnosis. If a person tests positive for the apolipoprotein E-4 (ApoE-4) allele it does not mean that the person will develop AD.

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? 1. "I no longer feel that I deserve the beatings my husband inflicts on me." 2. "My attendance at the meetings has helped me to see that I provoke my husband's violence." 3. "I enjoy attending the meetings because they get me out of the house and away from my husband." 4. "I can tolerate my husband's destructive behaviors now that I know they are common among alcoholics.

1. "I no longer feel that I deserve the beatings my husband inflicts on me."

Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. 1. Monitor vital signs. 2. Provide a safe environment. 3. Address hallucinations therapeutically. 4. Provide stimulation in the environment. 5. Provide reality orientation as appropriate. 6. Maintain NPO (nothing by mouth) status.

1. Monitor vital signs. 2. Provide a safe environment. 3. Address hallucinations therapeutically 5. Provide reality orientation as appropriate.

The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? 1. Ask the client why he started taking illegal drugs. 2. Ask the client about the amount of drug use and its effect. 3. Ask the client how long he thought that he could take drugs without someone finding out. 4. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home.

2. Ask the client about the amount of drug use and its effect. Rationale: Whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental and off-focus, and reflects the nurse's bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention.

An adult was brought to the emergency room. The patient's sensorium alternates between clouded and clear, and the patient becomes agitated both physically and verbally when approached. The patient's roommate states, "The patient was fine after getting up this morning but started talking crazy about 3 hours ago." The patient's cognitive impairment is most consistent with: A. Early-onset Alzheimer disease B. Delirium C. Sundown syndrome D. Dementia

B. Delirium

Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia? a. Setting the medications up monthly in a medication box b. Having the patient's family member administer the medication c. Posting reminders to take the medications in the patient's house d. Calling the patient weekly with a reminder to take the medication

ANS: B Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the drug. The other nursing actions will not be as effective in ensuring that the patient takes the medications.

The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? 1. Hypotension, ataxia, hunger 2. Stupor, lethargy, muscular rigidity 3. Hypotension, coarse hand tremors, lethargy 4. Hypertension, changes in level of consciousness, hallucinations

4. Hypertension, changes in level of consciousness, hallucinations Rationale: Symptoms associated with alcohol withdrawal delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions.

For which patient should the nurse prioritize an assessment for depression? 1 A patient in the early stages of Alzheimer's disease 2 A patient who is in the final stages of Alzheimer's disease 3 A patient experiencing delirium secondary to dehydration 4 A patient who has become delirious following an atypical drug response

A patient in the early stages of Alzheimer's disease A patient in the early stages of Alzheimer's disease is particularly susceptible to depression because the patient is acutely aware of his or her cognitive changes and the expected disease trajectory. Delirium is typically a shorter-term health problem that does not typically pose a heightened risk of depression.

A patient has been diagnosed with familial Alzheimer's disease. What characteristics are different in familial Alzheimer's disease when compared with those of sporadic disease? Select all that apply. 1 A rapid disease course 2 Presence of amyloid plaques 3 Loss of connections between neurons 4 A clear pattern of inheritance within the family 5 An early onset of the disease (before 60 years of age)

A rapid disease course A clear pattern of inheritance within the family An early onset of the disease (before 60 years of age) Familial Alzheimer's disease is characterized by a rapid disease course and a clear pattern of inheritance within the family. The disease onset is also early (before the age of 60 years). The presence of amyloid plaques and loss of connections between neurons are common characteristics in familial as well as sporadic Alzheimer's disease.

Which assessment findings are likely for an individual who recently injected heroin? A. Anxiety, restlessness, paranoid delusions B. Drowsiness, constricted pupils, slurred speech C. Muscle aching, dilated pupils, tachycardia D. Heightened sexuality, insomnia, euphoria

B. Drowsiness, constricted pupils, slurred speech

Which assessment finding represents a negative symptom of schizophrenia? A. Apathy B. Delusion C. Motor tic D. Hallucination

A. Apathy

You administer the Confusion Assessment Method (CAM) tool to differentiate among various cognitive disorders, primarily because A. Delirium can be reversed by treating the underlying causes. B. Depression is a common cause of dementia in older adults. C. Nursing care should be based on the cause of the cognitive impairment. D. Drug therapy with antipsychotic agents is indicated in the treatment of dementia.

A. Delirium can be reversed by treating the underlying causes Rationale: Delirium, a state of temporary but acute mental confusion, is a common, life-threatening, and possibly preventable syndrome in older adults. Clinically, delirium is rarely caused by a single factor. It is often the result of the interaction of the patient's underlying condition with a precipitating event.

Which signs and symptoms are associated with acute stress disorder and often observed in patients who have been sexually assaulted? Select All that Apply A. Flashbacks B. Depression C. Auditory hallucinations D. Outburst of anger E. Amnesia for the event

A. Flashbacks B. Depression D. Outburst of anger E. Amnesia for the event

A priority goal of treatment for the patient with AD is to A. Maintain patient safety. B. Maintain or increase body weight. C. Return to a higher level of self-care. D. Enhance functional ability over time.

A. Maintain patient safety.

Symptoms of withdrawal from opioids for which the nurse should assess include: A. Nausea, vomiting, diaphoresis, anxiety, and hyperreflexia. B. Mood lability, incoordination, fever, and drowsiness. C. Dilated pupils, tachycardia, elevated blood pressure, and elation. D. Excessive eating, constipation, and headache.

A. Nausea, vomiting, diaphoresis, anxiety, and hyperreflexia.

A patient becomes anxious and says, "There are worms under my skin eating the hair follicles." How would you classify this assessment finding? A. Positive symptom B. Negative symptom C. Cognitive symptom D. Depressive symptom

A. Positive symptoms

A patient undergoing alcohol rehabilitation decides to begin disulfiram therapy. Patient teaching should include the need to (Select all that apply) A. Read labels of all liquid medications B. Avoid aged cheeses C. Maintain an adequate dietary intake of sodium D. void alcohol-based products E. Wear sunscreen and avoid bright sunlight F. Avoid breathing fumes of paints, stains, and stripping compounds

A. Read labels of all liquid medications D. void alcohol-based products F. Avoid breathing fumes of paints, stains, and stripping compounds

Which guidelines should direct nursing care when deescalating an angry patient? Select All that Apply. A. Recognize the patient's need for increased personal space B. Identify the trigger for the anger C. Agree to demands as long as they won't result in harm to anyone D. Behave calmly and respectfully E. Intervene as quickly as possible

A. Recognize the patient's need for increased personal space B. Identify the trigger for the anger D. Behave calmly and respectfully E. Intervene as quickly as possible

A patient diagnosed with schizophrenia has received fluphenazine decanoate twice a month for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? A. Tardive dyskinesia B. Pseudoparkinsonism C. Anticholinergic effects D. Tourette's syndrome

A. Tardive dyskinesia

The physician mentions to the nurse that a client who is about to be admitted has "sundowning." The nurse can expect to assess nightly: A.agitation. B.lethargy. C.depression. D.mania.

A. agitation

The spouse of a 67-yr-old male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am exhausted from worrying all the time. I don't know what to do." Which actions are best for the nurse to take next (select all that apply)? a. Suggest that a long-term care facility be considered. b. Offer ideas for ways to distract or redirect the patient. c. Teach the spouse about adult day care as a possible respite. d. Suggest that the spouse consult with the physician for antianxiety drugs. e. Ask the spouse what she knows and has considered about dementia care options.

ANS: b. Offer ideas for ways to distract or redirect the patient. c. Teach the spouse about adult day care as a possible respite. e. Ask the spouse what she knows and has considered about dementia care options. The stress of being a caregiver can be managed with a multicomponent approach. This includes respite care, learning ways to manage challenging behaviors, and further assessment of what the spouse may already have considered for care options. The patient is in the early stages and does not need long-term placement. Antianxiety medications may be appropriate, but other measures should be tried first.

A patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patient's speech is fragmented and incoherent. c. The patient is oriented to person but disoriented to place and time. d. The patient has a history of increasing confusion over several years.

ANS: A The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia.

After reviewing the health record shown in the accompanying figure for a patient who has multiple risk factors for Alzheimer's disease (AD), which topic will be most important for the nurse to discuss with the patient? a. Tobacco use b. Family history c. Cholesterol level d. Head injury history

ANS: A Tobacco use is a modifiable risk factor for AD. The patient will not be able to modify the increased risk associated with family history of AD and past head injury. While the total cholesterol is borderline high, the high HDL indicates that no change is needed in cholesterol management.

The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which action should the nurse take? a. Have the patient take a mid-morning nap. b. Keep window blinds open during the day. c. Provide hourly orientation to time and place. d. Move the patient to a quiet room in the afternoon.

ANS: B A likely cause of sundowning is a disruption in circadian rhythms, and keeping the patient active and in daylight will help reestablish a more normal circadian pattern. Moving the patient to a different room might increase confusion. Taking a nap will interfere with nighttime sleep. Hourly orientation will not be helpful in a patient with dementia.

The nurse is administering a mental status examination to a patient who has hypertension. The nurse suspects depression when the patient responds to the nurse's questions with a. "Is that right?" b. "I don't know." c. "Wait, let me think about that." d. "Who are those people over there?"

ANS: B Answers such as "I don't know" are more typical of depression than dementia. The response "Who are those people over there?" is more typical of the distraction seen in a patient with delirium. The remaining two answers are more typical of a patient with mild to moderate dementia.

A patient seen in the outpatient clinic is diagnosed with mild cognitive impairment (MCI). Which action will the nurse include in the plan of care? a. Suggest a move into an assisted living facility. b. Schedule the patient for more frequent appointments. c. Ask family members to supervise the patient's daily activities. d. Discuss the preventive use of acetylcholinesterase medications.

ANS: B Ongoing monitoring is recommended for patients with MCI. MCI does not usually interfere with activities of daily living, acetylcholinesterase drugs are not used for MCI, and an assisted living facility is not indicated for a patient with MCI.

A patient who has severe Alzheimer's disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care? a. Encourage the patient to discuss events from the past. b. Maintain a consistent daily routine for the patient's care. c. Reorient the patient to the date and time every 2 to 3 hours. d. Provide the patient with current newspapers and magazines.

ANS: B Providing a consistent routine will decrease anxiety and confusion for the patient. Reorientation to time and place will not be helpful to the patient with severe AD, and the patient will not be able to read. The patient with severe AD will probably not be able to remember events from the past.

A patient is being evaluated for Alzheimer's disease (AD). The nurse explains to the patient's adult children that a. the most important risk factor for AD is a family history of the disorder. b. a diagnosis of AD is made only after other causes of dementia are ruled out. c. new drugs have been shown to reverse AD deterioration dramatically in some patients. d. brain atrophy detected by magnetic resonance imaging (MRI) would confirm the diagnosis of AD.

ANS: B The diagnosis of AD is usually one of exclusion. Age is the most important risk factor for development of AD. Drugs may slow the deterioration but do not reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in other diseases as well and does not confirm a diagnosis of AD.

Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had a fractured hip repair 2 days ago? a. Provide complete personal hygiene care for the patient. b. Remind the patient frequently about being in the hospital. c. Reposition the patient frequently to avoid skin breakdown. d. Place suction at the bedside to decrease the risk for aspiration.

ANS: B The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.

6. The early stage of AD is characterized by A. No noticeable change in behavior. B. Memory problems and mild confusion. C. Increased time spent sleeping or in bed. D. Incontinence, agitation, and wandering behavior.

B. Memory problems and mild confusion.

When administering a mental status examination to a patient with delirium, the nurse should a. wait until the patient is well-rested. b. administer an anxiolytic medication. c. choose a place without distracting stimuli. d. reorient the patient during the examination.

ANS: C Because overstimulation by environmental factors can distract the patient from the task of answering the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient's delirium.

When administering the Mini-Cog exam to a patient with possible Alzheimer's disease, which action will the nurse take? a. Check the patient's orientation to time and date. b. Obtain a list of the patient's prescribed medications. c. Ask the person to use a clock drawing to indicate a specific time. d. Determine the patient's ability to recognize a common object such as a pen.

ANS: C In the Mini-Cog, patients illustrate a specific time stated by the examiner by drawing the time on a clock face. The other actions may be included in assessment for Alzheimer's disease but are not part of the Mini-Cog exam.

The nurse's initial action for a patient with moderate dementia who develops increased restlessness and agitation should be to a. reorient the patient to time, place, and person. b. administer a PRN dose of lorazepam (Ativan). c. assess for factors that might be causing discomfort. d. assign unlicensed assistive personnel (UAP) to stay in the patient's room.

ANS: C Increased motor activity in a patient with dementia is frequently the patient's only way of responding to factors such as pain, so the nurse's initial action should be to assess the patient for any precipitating factors. Administration of sedative drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia. Assigning UAP to stay with the patient may also be necessary, but any physical changes that may be causing the agitation should be addressed first.

A patient is diagnosed with moderate dementia after multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. difficulty eating and swallowing. c. loss of recent and long-term memory. d. fluctuating ability to perform simple tasks.

ANS: C Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient's ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia.

A patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care? a. Reorient the patient several times daily. b. Have the family bring in familiar items. c. Place the patient in a room close to the nurses' station. d. Ask the patient why the wandering episodes have occurred.

ANS: C Patients at risk for problems with safety require close supervision. Placing the patient near the nurse's station will allow nursing staff to observe the patient more closely. The use of "why" questions can be frustrating for patients with AD because they are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patient's short-term memory loss, reorientation will not help prevent wandering behavior. Because the patient had wandering behavior at home, familiar objects will not prevent wandering.

Which action will help the nurse determine whether a new patient's confusion is caused by dementia or delirium? a. Ask about a family history of dementia. b. Administer the Mini-Mental Status Exam. c. Use the Confusion Assessment Method tool. d. Obtain a list of the patient's usual medications.

ANS: C The Confusion Assessment Method tool has been extensively tested in assessing delirium. The other actions will be helpful in determining cognitive function or risk factors for dementia or delirium, but they will not be useful in differentiating between dementia and delirium.

Which hospitalized patient will the nurse assign to the room closest to the nurses' station? a. Patient with Alzheimer's disease who has long-term memory deficit b. Patient with vascular dementia who takes medications for depression c. Patient with new-onset confusion, restlessness, and irritability after surgery d. Patient with dementia who has an abnormal Mini-Mental State Examination

ANS: C This patient's history and clinical manifestations are consistent with delirium. The patient is at risk for safety problems and should be placed near the nurses' station for ongoing observation. The other patients have chronic symptoms that are consistent with their diagnoses but are not at immediate risk for safety issues.

A 72-yr-old patient is brought to the clinic by the patient's spouse, who reports that the patient is unable to solve common problems around the house. To obtain information about the patient's current mental status, which question should the nurse ask the patient? a. "Are you sad right now?" c. "What did you eat for lunch?" b. "How is your self-image?" d. "Where were you were born?"

ANS: C This question tests the patient's short-term memory, which is decreased in the mild stage of Alzheimer's disease or dementia. Asking the patient about her birthplace tests for remote memory, which is intact in the early stages. Questions about the patient's emotions and self-image are helpful in assessing emotional status, but they are not as helpful in assessing mental state.

After change-of-shift report on the Alzheimer's disease/dementia unit, which patient will the nurse assess first? a. Patient who has not had a bowel movement for 5 days b. Patient who has a stage II pressure ulcer on the coccyx c. Patient who is refusing to take the prescribed medications d. Patient who developed a new cough after eating breakfast

ANS: D A new cough after a meal in a patient with dementia suggests possible aspiration, and the patient should be assessed immediately. The other patients also require assessment and intervention but not as urgently as a patient with possible aspiration or pneumonia.

The nurse is concerned about a postoperative patient's risk for injury during an episode of delirium. The most appropriate action by the nurse is to a. secure the patient in bed using a soft chest restraint. b. ask the health care provider to order an antipsychotic drug. c. instruct family members to remain at the patient's bedside and prevent injury. d. assign unlicensed assistive personnel (UAP) to stay with and reorient the patient.

ANS: D The priority goal is to protect the patient from harm. Having a UAP stay with the patient will ensure the patient's safety. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have many side effects. Restraints are not recommended because they can increase the patient's agitation and disorientation.

The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? A. Auditory hallucinations B. Poor personal hygiene C. Psychomotor agitation D. Delusions of grandeur

B. Poor personal hygiene

Which patient may face the greatest risk of developing delirium? 1 A patient with fibromyalgia whose chronic pain recently has worsened 2 A patient with a fracture who has spent the night in the emergency department 3 An older patient whose recent computed tomography (CT) shows brain atrophy 4 An older patient who takes multiple medications to treat various health problems

An older patient who takes multiple medications to treat various health problems Polypharmacy is implicated in many cases of delirium, and this phenomenon is especially common among older adults. Brain atrophy, if associated with cognitive changes, is indicative of dementia. Alterations in sleep and environment, as well as pain, may cause delirium, but this is less of a risk than in an older adult who takes multiple medications.

The nurse is caring for a client with chronic confusion who often yells and screams when touched. Which nursing intervention is most appropriate when caring for this client? A. Provide a large clock and calendar for the patient to read. B. Use removable restraints such as a roll-waist belt to prevent wandering. C. Approach the patient so the nurse can be seen clearly. D. Place the patient in a room close to the nurses' station for frequent observation.

C. Approach the patient so the nurse can be seen clearly.

The nurse is caring for a hospitalized patient. Which observation does the nurse identify as a possible beginning sign of delirium? 1 Pain level of 5 2 Awake at 3 AM 3 Drop in blood pressure 4 Reports of being hungry

Awake at 3 AM Early manifestations of delirium include insomnia. Being awake at 3 AM could indicate this early warning sign. Pain, hypotension, and increased hunger are not identified as manifestations of delirium.

A patient with schizophrenia, disorganized type, approaches the nurse and says "It's beat, it's eat. No room for doom." How will the nurse correctly assess this verbalization? A. Neologisms B. Ideas of reference C. Clanging D. Associative looseness

C. Clanging

A client with early dementia asks the nurse to find her mother, who is deceased. What is the nurse's most appropriate response? A. "We can call her in a little while if you want." B. " Your mother died over 20 years ago." C. "What did your mother look like?" D. "I'll ask your father to find her when he visits."

B. " Your mother died over 20 years ago."

A patient with paranoia and becomes agitated and threatens to assault another staff person. He tells you, "You're the only one I think I can trust. But can I? Are you going to take their side?" Select the best initial intervention for Mr. Oswald at this point. A. Say, "If you do not calm down, seclusion will be needed." B. Address him with simple directions and a calming voice. C. Help him focus by rubbing his shoulders. D. Offer him a dose of antipsychotic medication.

B. Address him with simple directions and a calming voice. A calming voice and simple, nonemotional directions can help de-escalate the patient's anxiety. This is an initial intervention, so do not threaten him with seclusion or resort to antipsychotics. Rubbing his shoulders is inappropriate and may contribute to anxiety, not calm.

Which patient behavior is a criterion for mechanical restraint? A. Screaming profanities B. Assaulting a staff person C. Refusing a medication dose D. Throwing a pillow at another patient

B. Assaulting a staff person Indications for the use of mechanical restraint include protecting the patient from self-harm and preventing the patient from assaulting others.

5. Which statement(s) accurately describe(s) mild cognitive impairment (select all that apply)? A. Always progresses to AD B. Caused by variety of factors and may progress to AD C. Should be aggressively treated with acetylcholinesterase drugs D. Caused by vascular infarcts that, if treated, will delay progression to AD E. Patient is usually not aware that there is a problem with his or her memory

B. Caused by variety of factors and may progress to AD

A person has recently abused morphine. The person's pupils would most likely be A. Dilated B. Constricted C. Symmetrical D. Unresponsive to light

B. Constricted

45-year-old patient shows marked cognitive impairment that has developed progressively over several months. A family member reports the patient's father had early-onset dementia. What research-based information can be given to the family in response to their concerns about the patient developing early-onset dementia? A. The risk for developing the condition is about 50% only if both parents were affected. B. The greatest risk exists for relatives of individuals diagnosed with Alzheimer disease before age 55 years. C. Added risk is present only for people with Down syndrome, so relatives without Down syndrome are essentially safe D. Results of the research on genetic predisposition and its effect on the development of early-onset dementia are still unclear.

B. The greatest risk exists for relatives of individuals diagnosed with Alzheimer disease before age 55 years. Rationale: The risk for development of Alzheimer disease (AD) is greater for relatives of people with the illness than it is for those with no family history of AD. An individual with one parent with early-onset AD has a 50% chance of developing it before the age of 55 years as well. Those offspring who do not inherit early-onset AD do not pass it on to their own children and presumably have the same risk of developing AD much later in life as does the general population. Down syndrome does appear to be a risk factor for early-onset AD

Rosa, a 78-year-old patient with Alzheimer's disease, picks up her glasses from the bedside table but does not recognize what they are or their purpose. She is experiencing: A.apraxia. B.agnosia. C.aphasia. D.agraphia.

B.agnosia.

While completing a health history the nurse identifies that a patient is at risk for developing dementia. What data does the nurse use to make this clinical determination? Select all that apply. 1 BMI 32.7 2 A 10-year history of type 2 diabetes mellitus 3 Takes over-the-counter analgesics for arthritic pain 4 Parent died at the age of 85 from cardiomyopathy and renal failure 5 Takes two antihypertensive medications and maintains a blood pressure 150/88 mm Hg

BMI 32.7 A 10-year history of type 2 diabetes mellitus Takes two antihypertensive medications and maintains a blood pressure 150/88 mm Hg Risk factors for dementia include obesity, diabetes mellitus, obesity, and hypertension. A BMI of 32.7 indicates obesity. The patient was diagnosed with type 2 diabetes mellitus 10 years ago. The patient's current blood pressure on two antihypertensive medications is 150/88 mm Hg. Arthritis or the use of over-the-counter analgesics are not risk factors for the development of dementia. A familial history of cardiomyopathy and renal failure are not risk factors for the development of dementia.

Shortly before treatment, after crying and begging him to get help, the patient's girlfriend stayed home from a planned night out with her friends to pour all the alcohol in his apartment down the drain. What type of behavior is evident? A. Enabling B. Tolerance C. Codependence D. Use of defense mechanisms

C. Codependence

An older patient is admitted to the hospital with a urinary infection and possible bacterial sepsis. The family is concerned because the patient is confused and not able to carry on a conversation. Which statement by the nurse is most appropriate? A. "Depression is a common cause of confusion in older adults in the hospital." B. "It is normal for an older person to have cognitive problems while in the hospital." C. "The mental changes are most likely caused by the infection and most often reversible." D. "Drug therapy with antipsychotic agents is indicated to slow the progression of dementia."

C. "The mental changes are most likely caused by the infection and most often reversible." Rationale: Delirium, a state of temporary but acute mental confusion, is a common, life-threatening, and possibly preventable syndrome in older adults. Clinically, delirium is rarely caused by a single factor. It is often the result of the interaction of the patient's underlying condition with a precipitating event.

2. Vascular dementia is associated with A. Transient ischemic attacks. B. Bacterial or viral infection of neuronal tissue. C. Cognitive changes secondary to cerebral ischemia. D. Abrupt changes in cognitive function that are irreversible

C. Cognitive changes secondary to cerebral ischemia.

4. Dementia with Lewy bodies (DLB) is characterized by A. Remissions and exacerbations over many years. B. Memory impairment, muscle jerks, and blindness. C. Parkinsonian symptoms, including muscle rigidity. D. Increased intracranial pressure secondary to decreased CSF drainage.

C. Parkinsonian symptoms, including muscle rigidity.

The parents of a child diagnosed with an intellectual impairment ask what can be expected? What goal should the nurse share with the parents? A.To provide age-appropriate play interactions B.To help the child develop vocational skills C.To assist the child in reaching his optimum development D.To help families adjust to what the future care will include

C.To assist the child in reaching his optimum development

A patient's dementia is suspected of having a vascular cause. Which diagnostic test does the nurse expect to be prescribed to validate this suspicion? 1 Lipid panel 2 CT scan of the brain 3 Pituitary hormone levels 4 Partial thromboplastin time

CT scan of the brain The diagnosis of dementia related to vascular causes is based on cognitive loss, vascular brain lesions demonstrated by neuroimaging techniques, and the exclusion of other causes of dementia. Therefore the nurse expects that a CT scan of the brain will be prescribed for this patient. A lipid panel, pituitary hormone levels, and partial thromboplastin time will not identify a vascular cause for this patient's dementia.

The nurse is providing care to an adult patient who is diagnosed with mild cognitive impairment (MCI). The nurse anticipates that which treatment will be prescribed? 1 Donepezil 2 Rivastigmine 3 Continued monitoring 4 Placement in assisted living

Continued monitoring Currently the primary treatment of MCI consists of ongoing monitoring. There is little evidence that cholinesterase inhibitors, such as donepezil and rivastigmine, affect progression to dementia or cognitive test scores in people with MCI. MCI is marked by symptoms of memory problems severe enough to be noticed and measured, but not compromising a person's independence; therefore placement in assisted living is not anticipated.

A patient diagnosed with alcohol use disorder asks, "How will Alcoholics Anonymous (AA) help me?" Select the nurse's best response. A. The goal of AA is for members to learn controlled drinking with the support of a higher power." B. "You will be assigned a sponsor who will plan your treatment program." C. "You must make a commitment to permanently abstain from alcohol and other drugs." D. "An individual is supported by peers while striving for abstinence one day at a time."

D. "An individual is supported by peers while striving for abstinence one day at a time." Rationale: Admitting to being an alcoholic, making an attempt to remain alcohol-free for a day at a time, and receiving support from peers are basic aspects of AA. The other options are incorrect.

During the third week of treatment, the spouse of a patient in a rehabilitation program for substance abuse says, "After this treatment program, I think everything will be all right." Which remark by the nurse will be most helpful to the spouse? A. "It is good that you are supportive of your spouse's sobriety and want to help maintain it." B. "It will be important for you to structure life to avoid as much stress as you can and provide social protection." C. "Addiction is a lifelong disease of self-destruction. You will need to observe your spouse's behavior carefully." D. "While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol."

D. "While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol."

A nurse caring for a patient with Alzheimer disease can anticipate that the family will most likely need information about: A. Antimetabolites B. Benzodiazepines C. Immunosuppressants D. Acetylcholinesterase inhibitors

D. Acetylcholinesterase inhibitors Rationale: Acetylcholinesterase inhibitors are often prescribed to treat Alzheimer disease. These drugs allow greater concentration of acetylcholine in the brain, thereby improving cognitive function.

A patient becomes increasingly agitated, and when you come back from break, you find out he wants to talk to you alone. Your response is to A. Respect his privacy and see him alone. B. Do not speak to him in private; it's time for the team to confront him (calmly) as a group. C. Ask for him to be put in restraints first or take security staff with you. D. Go speak to him in a nonconfrontational way, but ensure that there are other staff nearby for backup.

D. Go speak to him in a nonconfrontational way, but ensure that there are other staff nearby for backup. Ensure that there is enough staff for backup. Only one person should talk to the patient, but staff need to maintain an unobtrusive presence in case the situation escalates. Avoid confrontation with the patient, either through verbal means or through a "show of force" with security guards. Verbal confrontation and discussion of the incident must occur when the patient is calm. A show of force by security guards may serve to escalate the patient's behavior; therefore, security personnel are better kept in the background until they are needed to assist.

A nurse is assigned the care of four patients who are detoxifying from alcohol. The patient with which symptom would be the nurse's highest priority? A. Fine motor tremors B. Diaphoresis C. Diarrhea D. Hallucinations and delusions

D. Hallucinations and delusions

The daughter of a patient with early familial Alzheimer's disease (AD) asks how AD is different from forgetfulness. You describe early warning signs of AD, including A. Forgetting a colleague's name at a party B. Repeatedly misplacing car keys or a wallet C. Leaving a pot on the stove that boils dry and burns D. Having no memory of preparing a meal and forgetting to serve or eat it

D. Having no memory of preparing a meal and forgetting to serve or eat it Rationale: Memory loss that affects job skills: Frequent forgetfulness or unexplainable confusion at home or in the workplace may signal that something is wrong. This type of memory loss goes beyond forgetting an assignment, a colleague's name, a deadline, or a phone number. Difficulty performing familiar tasks: It is not abnormal for most people to become distracted and to forget something (e.g., leave something on the stove too long). People with Alzheimer's disease (AD) may cook a meal but then forget not only to serve it but also that they made it. Misplacing things: For many individuals, temporarily misplacing keys, purses, or wallets is a normal albeit frustrating event. Persons with AD may put items in inappropriate places (e.g., eating utensils in clothing drawers) but have no memory of how they got there.

Which statement is an accurate depiction of sexual assault? A. Rape is a sexual act B. Women are usually raped by strangers C. Rape is usually an impulsive act D. Most rapes occur in the home

D. Most rapes occur in the home

3. The clinical diagnosis of dementia is based on A. CT or MRS. B. Brain biopsy. C. Electroencephalogram. D. Patient history and cognitive assessment.

D. Patient history and cognitive assessment.

Loose associations in a person with schizophrenia indicate A. paranoia. B. Mood instability. C. Depersonalization. D. Poorly organized thinking

D. Poorly organized thinking

The nurse is conducting a program for parents with toddlers who have a variety of developmental/intellectual disabilities. Other than the basic activities of daily living, what topic should the nurse should emphasize? A. Play activities B. Socialization activities C. The need for being held D. Safety needs

D. Safety needs

A patient with schizophrenia refuses to take his medication because he believes he is not ill. What is the most likely explanation for this belief? A. Stigma causes the patient to refuse to admit his mental illness. B. The patient is unable to face having an illness and is in denial. C. Command hallucinations are instructing him to deny the illness. D. The illness itself is preventing the patient from realizing he is ill.

D. The illness itself is preventing the patient from realizing he is ill.

1. Dementia is defined as a A. syndrome that results only in memory loss. B. disease associated with abrupt changes in behavior. C. disease that is always due to reduced blood flow to the brain. D. syndrome characterized by cognitive dysfunction and loss of memory.

D. syndrome characterized by cognitive dysfunction and loss of memory.

•A client is brought to the hospital by her daughter, who visited this morning and found her mother to be confused and disoriented. When the client is admitted, the daughter states, "I'll take her glasses and hearing aid home, so they don't get lost." The best reply for the nurse would be: A."That will be fine. I'll have you sign our hospital release form." B."Because we do not have a copy of durable power of attorney, we cannot release them to you." C."Don't worry. You can leave them at her bedside. We are insured for losses of this sort." D."I would like to have your mother wear them. It will help her to be less confused."

D."I would like to have your mother wear them. It will help her to be less confused."

•Claire is a student nurse working with Carl, an 82-year-old patient with dementia. She finds herself frustrated at times by not knowing how best to care for or communicate with Carl. Which of the following statements she could make to Carl illustrates best care practice? A.Lighthearted banter: "Carl, you look great today in your new sweater, you handsome devil!" B.Limit setting: "Carl, you cannot yell out in your room. You are upsetting other patients." C.Firm direction: "You will take a shower this morning; there is no debating about it so don't try to argue." D.Positive regard: "Carl, I am glad to be here caring for you today. Let's talk about your plans for the day."

D.Positive regard: "Carl, I am glad to be here caring for you today. Let's talk about your plans for the day."

The nurse caring for a client with Alzheimer's disease can anticipate that the family will need information about therapy with: A.antihypertensives. B.benzodiazepines. C.immunosuppressants. D.acetylcholinesterase inhibitors.

D.acetylcholinesterase inhibitors.

The nurse is caring for the patient with Alzheimer's disease (AD). The family asks the nurse how their family member got the condition. What response by the nurse is most appropriate? 1 Long-term illegal drug abuse always leads to AD. 2 Low cholesterol levels can make the dementia worse. 3 Malnutrition can increase your chances of getting the disease. 4 Diabetes greatly increases a person's chances of developing AD.

Diabetes greatly increases a person's chances of developing AD. Diabetes is a dramatic risk factor to people with dementia. Insulin resistance associated with diabetes interferes with how the body breaks down protein amyloid plaques found in the brain tissue of AD patients. Obesity, not malnutrition and high cholesterol, are also risk factors. Long-term drug abuse is not a known risk factor in developing the disease.

The nurse is providing discharge teaching to the family of a patient who is diagnosed with Alzheimer's disease (AD). Which interventions are appropriate for the nurse to recommend to enhance the patient's safety within the home environment? Select all that apply. 1 Increasing fluid intake 2 Ensuring a well-lit stairwell 3 Tacking down carpet edges 4 Installing grab rails by the toilet 5 Placing throw rugs on hardwood flooring

Ensuring a well-lit stairwell Tacking down carpet edges Installing grab rails by the toilet Interventions that are appropriate to enhance safety for the patient diagnosed with AD in the home environment include having stairwells well lit, tacking down carpet edges, and installing grab rails by the toilet. The use of throw rugs is a safety hazard and this is not recommended. Although increasing fluid intake is appropriate for the patient with AD, this is an intervention to decrease the patient's risk for infection, not to promote safety within the home environment.

The nurse is caring for a patient with delirium. The patient becomes severely agitated. Which risk is the nurse's priority concern for this patient? 1 Falls 2 Disorientation 3 Thiamine deficiency 4 Hypoactive motor function

Falls A patient experiencing severe agitation is at risk for falls, which pose the greatest immediate risk to the patient's well-being. The patient experiencing severe delirium is most likely disoriented, but this is a characteristic, rather than a risk, of delirium. A thiamine deficiency may be related to the cause of the delirium, not an effect of the delirium. A patient with delirium will have hyperactive, not hypoactive, motor function.

Which professionals have a high risk of developing Alzheimer's disease or another type of dementia? Select all that apply. 1 Fishermen 2 Tennis players 3 Football players 4 Race car drivers 5 Military members

Football players Race car drivers Military members Head trauma is a risk factor for dementia. Football players, military members, and race car drivers are at elevated risk of getting injured and eventually developing dementia. Tennis players and fishermen have a low risk of head trauma and therefore are at low risk of developing dementia related to their profession.

Which nursing intervention is most appropriate when caring for patients with dementia? 1 Avoid direct eye contact. 2 Lovingly call the patient "honey" or "sweetie." 3 Give simple directions, focusing on one thing at a time. 4 Treat the patient according to his or her age-related behavior.

Give simple directions, focusing on one thing at a time. When dealing with patients with dementia, tasks should be simplified, giving directions using gestures or pictures and focusing on one thing at a time. The nurse should use gentle touch and direct eye contact. Calling the patient "honey" or "sweetie" can be condescending and does not demonstrate respect. It is best to treat these patients as adults, with respect and dignity, even when their behavior is childlike.

A patient in the coronary care unit begins to exhibit signs of delirium. The nurse identifies that which factors may have contributed to the acute onset of symptoms? Select all that apply. 1 Hard of hearing 2 History of heart failure 3 Indwelling urinary catheter 4 Intravenous fluid administration 5 Anesthesia for pacemaker insertion surgery

Hard of hearing History of heart failure Anesthesia for pacemaker insertion surgery Delirium can occur after a relatively minor insult in a vulnerable patient. Underlying health problems such as heart failure or sensory limitations may contribute to the development of delirium. In other patients it may take a combination of factors such as anesthesia and surgery to precipitate delirium. For this patient, a hearing deficit, history of heart failure, and anesthesia for pacemaker insertion can be identified as factors contributing to the development of delirium. An indwelling urinary catheter and intravenous fluid administration are not identified as precipitating factors for delirium.

Select the appropriate manner to interact with an older adult patient who recently became confused and agitated in the intensive care unit. Select all that apply. 1 Correct any misstatements made by the patient. 2 Have a calm and reassuring approach with the patient. 3 Turn the television on in the room to distract the patient. 4 Reorient the patient and have clock and calendar visible to the patient. 5 Make sure the patient is wearing his or her own eyeglasses and hearing aids.

Have a calm and reassuring approach with the patient. Reorient the patient and have clock and calendar visible to the patient. Make sure the patient is wearing his or her own eyeglasses and hearing aids. The patient has developed delirium, which is common among elderly patients in intensive care units. A calm, reassuring approach enhances a feeling of security. Wearing eye glasses and hearing aids assists the patient in communication. Reorientation verbally with reinforcement visuals such as a clock is helpful. Correcting all misstatements interferes with patient trust. The environment should not be overstimulating, so the television should be off.

A nurse is caring for a patient with Alzheimer's disease in an adult day care facility. What are the nursing management goals that will help this patient? Select all that apply. 1 Have dignity maintained 2 Maintain functional ability 3 Have personal care needs met 4 Learn to be dependent on the nurse 5 Get registered in a long-term care facility

Have dignity maintained Maintain functional ability Have personal care needs met The overall goals of nursing management for patients with Alzheimer's disease are to maintain functional ability, to maintain dignity, and to have personal care needs met. Owing to the cognitive decline, the patient may not be able to perform all activities; the nurse should aim to maintain the patient's functional ability as much as possible. Functional ability helps to preserve patient's dignity. The nurse should ensure that the personal care needs of the patient are met, either by the patient him- or herself (preferably) or by a caregiver (if the patient is unable). The patient should not be encouraged to become dependent on the nurse or the caregiver, because it would decrease the patient's functional ability and self-respect. In early stages, the patient can be managed at home, with adult day care as a welcome aid (and break), and a long-term care facility may not be needed.

A nurse is teaching caregivers about the safety measures to reduce the risk of injuries for a patient with Alzheimer's disease. Which measures should be included in the teaching? Select all that apply. 1 Have stairwells well lit 2 Remove extension cords 3 Tack down carpet edges 4 Install handrails in the bath 5 Plain mats to be used in tub or shower

Have stairwells well lit Remove extension cords Tack down carpet edges Install handrails in the bath Owing to the decline in cognitive functions in Alzheimer's disease, the patient may be unable to navigate physical spaces and interpret environmental cues. Therefore to ensure personal safety, the extension cords should be removed, the stairwell should be lit properly, and the carpet edges should be tacked down. Installing handrails in the bath may help prevent falls. Loose extension cords and use of plain mats increase the risk of falls.

The nurse is providing care to an adult patient who is diagnosed with moderate Alzheimer's disease (AD). Which assessment data indicate that the patient has progressed from moderate to severe AD? 1 Needing assistance with dressing 2 Having difficulty eating and swallowing 3 Having more trouble following directions 4 Lacking judgment and beginning to wander

Having difficulty eating and swallowing Difficulty eating and swallowing is a clinical manifestation associated with severe AD and indicates the patient has progressed from moderate to severe AD. Needing assistance with dressing, having trouble following directions, and lacking judgment and wandering are all behaviors associated with moderate AD.

A spouse of a patient, just diagnosed with Alzheimer's disease in the mild stage, asks the nurse how to plan for the future and make treatment decisions. What is the best response by the nurse? 1 Medicine is researching treatments for Alzheimer's disease actively and a cure may be near. 2 Discussing advanced directives may cause the Alzheimer's disease to progress more quickly. 3 Disease progression is uniform and decisions about treatment can be made after the patient is comfortable with the diagnosis. 4 Health care decisions, including advanced directives, should be made while the patient is able to participate in the decision making.

Health care decisions, including advanced directives, should be made while the patient is able to participate in the decision making. The nurse should assist the spouse and patient to look at the future realistically and make health care decisions while the patient has the capacity to participate in the process. Progression of Alzheimer's disease varies with the individual. Offering the spouse a possible cure is false reassurance. The patient may not achieve a comfort level with the diagnosis.

A patient with diabetes mellitus wishes to know why diabetes increases the risk of developing dementia. How should the nurse explain this connection to the patient? 1 High blood glucose eliminates oxidative stress that damages cells. 2 Insulin resistance promotes the body's ability to break down amyloid. 3 High glucose levels reduce cholesterol levels, preventing atherosclerosis. 4 High glucose levels cause microangiopathy, which damages blood vessels of the brain.

High glucose levels cause microangiopathy, which damages blood vessels of the brain. Diabetes is one of the major risk factors of dementia. Diabetes mellitus damages the small vessels throughout the body, including those of the brain. A compromised oxygen supply due to these damaged blood vessels may be responsible for progressive cognitive decline in patients with diabetes mellitus. Insulin resistance does not promote the body's ability to break down amyloid; rather, it interferes with it. Amyloid protein is responsible for forming brain plaques in Alzheimer's disease. High blood glucose does not eliminate oxidative stress; it produces oxygen-containing molecules that can damage cells. In addition, high blood glucose, coupled with high cholesterol, accelerates atherosclerosis, which contributes to vascular dementia.

The nurse is providing care to a pediatric patient with dementia. Which is a ventricular disorder that could be the cause of the dementia in this patient? 1 Head injury 2 Brain tumor 3 Hydrocephalus 4 Hepatic encephalopathy

Hydrocephalus Hydrocephalus is a potentially reversible ventricular disorder that can cause dementia. A traumatic head injury is also a potentially reversible condition that can cause dementia. However, this is not a ventricular disorder. A primary brain tumor can also cause dementia but is not a ventricular disorder. Hepatic encephalopathy is a systemic disease that can cause dementia.

Which statement is true regarding the pathophysiology of Alzheimer's disease (AD)? 1 Plaques and neurofibrillary tangles are unique to patients with AD. 2 Neurofibrillary tangles are absent on the neurons of patients with AD. 3 By the final stage of AD, the patient's brain tissue is significantly enlarged. 4 In patients diagnosed with AD, more plaques appear in certain parts of the brain.

In patients diagnosed with AD, more plaques appear in certain parts of the brain. In patients diagnosed with AD, more plaques appear in certain parts of the brain. By the final stage of AD, brain tissue is significantly atrophied, not enlarged. Plaques are not unique to patients with AD. Neurofibrillary triangles are present, not absent, on the neurons of patients with AD.

A group of patients who have a high risk of developing Alzheimer's disease attend adult day care. What interventions would help promote mental health? Select all that apply. 1 Learn new skills 2 Exercise regularly 3 Solve crossword puzzles 4 Consume alcohol in moderation 5 Avoid crowds and social gatherings

Learn new skills Exercise regularly Solve crossword puzzles There is no definite way to prevent Alzheimer's disease, but there are several steps that can help keep the brain healthy. Solving puzzles and learning new skills strengthens the brain connections and promotes new ones. Exercising regularly can decrease the risk of cognitive decline. Drinking can damage brain cells, so it should be avoided in patients with Alzheimer's disease. Avoiding crowds and social gatherings can isolate the patient, further deteriorating the condition.

The nurse is providing care to an adult patient that is diagnosed with mild Alzheimer's disease (AD). Which distraction activity is appropriate for the patient? 1 Looking at family photos 2 Looking at dangling ribbons 3 Playing a board game appropriate for a school-age child 4 Participating in an activity appropriate for the preschool-age child

Looking at family photos An appropriate distraction activity for an adult patient diagnosed with mild AD is looking at family photos. Activities appropriate for school-age and preschool-age children would be appropriate for a patient diagnosed with moderate AD. Looking at dangling ribbons is a distraction activity for a patient who is diagnosed with severe AD.

A nurse is assessing an older adult patient with memory loss. What symptoms are found in the patient with Alzheimer's disease, separate from normal forgetfulness? Select all that apply. 1 Loses sense of time 2 Jokes about memory loss 3 Forgets what an item is used for 4 Little awareness of cognitive problems 5 Momentarily forgets acquaintance's name

Loses sense of time Jokes about memory loss Forgets what an item is used for Little awareness of cognitive problems The manifestations of Alzheimer's disease include a change in cognitive functioning and memory loss such as forgetting what an item is used for, a loss of sense of time, and, in later stages, having little or no awareness of cognitive problems. Momentarily forgetting an acquaintance's name is normal. Joking about memory loss may indicate mild cognitive impairment and ample awareness of one's cognitive problems.

A patient with behavioral changes is scheduled for neurologic testing. Which findings does the nurse identify as supporting a diagnosis of dementia? Select all that apply. 1 Loss of memory 2 Early awakening from sleep 3 Hyperactive body movements 4 Difficulty with normal conversation 5 Changes developing over the last few days

Loss of memory Difficulty with normal conversation Dementia is often diagnosed when two or more brain functions, such as memory loss or language skills, are significantly impaired. Early awakening from sleep is associated with depression. Hyperactive body movements are associated with either dementia or delirium. Behavior changes that developed over the last few days are manifestations of delirium.

The nurse recognizes that which intervention may be beneficial to a patient in the early stages of Alzheimer's disease (AD)? 1 Admission to an AD unit 2 Respite care once a week 3 Use of antipsychotic drugs 4 Memory aids such as calendars

Memory aids such as calendars For patients who are in the early stages of AD, memory aides such as the use of a calendar are often beneficial. Admission to an AD unit and weekly respite care may be appropriate as the disease progresses. Agitation and aggressive behavior do not typically occur in the early stages of AD; therefore the use of antipsychotic drugs is not appropriate. Antidepressants may be needed in the early stages of AD because many patients develop depression in this phase.

The nurse is caring for an older adult patient. For what symptoms of dementia should the nurse be observant? Select all that apply. 1 Seizures 2 Dyspnea 3 Memory loss 4 Cognitive dysfunction 5 Abrupt changes in behavior

Memory loss Cognitive dysfunction Abrupt changes in behavior In dementia, there is progressive neurodegeneration, and vascular changes lead to cognitive impairment. The cognitive impairment manifests as abrupt changes in behavior, memory loss, and cognitive dysfunction, which are all symptoms of dementia. Other symptoms include dysfunction or loss of orientation, attention, language, judgment, and reasoning. Presence of seizures indicates other neurologic problems. Dyspnea is a manifestation of impaired respiratory function.

What does the letter "M" represent in the mnemonic, "DELIRIUM," to remember causes of delirium? 1 Medication 2 Malnutrition 3 Memory loss 4 Metabolic disorders

Metabolic disorders The letter "M" represents metabolic disorders in the mnemonic of causes for delirium. The "R" for Rx represents medication. The "D" for dementia and dehydration represents memory loss. Malnutrition is not part of this mnemonic.

The nurse is working in a health care facility with patients with neurologic disease. The nurse understands that some neurologic diseases may be curable if detected early. Which disease, if detected early, is curable? 1 Parkinsonism 2 Alzheimer's disease 3 Dementia with Lewy bodies 4 Normal pressure hydrocephalus

Normal pressure hydrocephalus Normal pressure hydrocephalus is an uncommon disorder characterized by obstruction in the flow of cerebrospinal fluid, causing a buildup of the fluid in the brain. If diagnosed early, it is treatable by surgery in which a shunt is inserted to divert the fluid away from the brain. Alzheimer's disease, Parkinsonism, and dementia with Lewy bodies are progressively neurodegenerative diseases. There is no cure for these diseases, only symptom management.

The nurse visits an older adult patient at home. The patient's spouse expresses concern that the patient is developing Alzheimer's disease. What behavioral pattern in an older adult may indicate normal forgetfulness related to aging? Select all that apply. 1 Becomes lost in familiar places 2 May not remember knowing a person 3 Occasionally forgets to run an errand 4 May forget an event from the distant past 5 Sometimes misplaces keys, eyeglasses, or other items

Occasionally forgets to run an errand May forget an event from the distant past Sometimes misplaces keys, eyeglasses, or other items The older adult with normal forgetfulness may occasionally forget to run an errand or may forget an event from the distant past. An older adult may also sometimes misplace keys, eyeglasses, or other items. On the other hand, a person with Alzheimer's disease may not remember knowing a person or may get lost in familiar places, owing to profound memory loss.

A patient diagnosed with Alzheimer's disease is prescribed donepezil. What is the purpose of this medication? 1 Possibly slows the rate of cognitive decline. 2 Dissolves the amyloid plaques in the brain tissue. 3 Treats the associated depression the patient experiences. 4 Reverses the progression of the stages of Alzheimer's disease.

Possibly slows the rate of cognitive decline. Donepezil is a cholinesterase inhibitor medication. This medication slows the breakdown of acetylcholine, a neurotransmitter in the brain, and possibly slows the rate of cognitive decline. There is no effect on the plaques of amyloid occurring in the brain with aging. There are more of these plaques in persons with Alzheimer's disease. Patients with concurrent depression may be treated with selective serotonin uptake inhibitors (SSRI), such as sertraline. The medication does not reverse or cure Alzheimer's disease.

A patient with a history of Alzheimer's disease is seen in the health care provider's office. Which symptom is consistent with the mild stage of the disease? 1 Patient needs help to get dressed. 2 Patient has difficulty in learning new skills. 3 Patient is unable to walk without assistance. 4 Patient has difficulty recognizing family members.

Patient has difficulty in learning new skills. In the mild or early stage of Alzheimer's disease, the patient experiences short-term memory impairment and has difficulty learning new skills. In the moderate stage, the patient has difficulty in getting dressed independently and recognizing family members. The severe stage encompasses greater physical disability, including difficulty with walking.

A nurse in a long-term care facility is caring for a patient with Alzheimer's disease. The patient, who is usually cooperative and calm, is agitated and refusing care from the nursing assistant. What action should the nurse do first? 1 Notify the health care provider and obtain a medication to treat the agitation. 2 Notify the patient's family and ask if someone could come and sit with the patient. 3 Perform a physical assessment, including monitoring vital signs and signs of pain. 4 Take the nursing assistant to the patient and explain that cooperation is expected.

Perform a physical assessment, including monitoring vital signs and signs of pain. Initially the nurse should assess the patient's physical status to determine if the patient is experiencing some physical ailment. Consider that the patient's dementia limits the ability to express needs. Precipitating factors causing the behavior change should be thoroughly investigated before asking a family member to sit with the patient or administering medication to control agitation. Attempting to reason with the patient will further agitate the patient.

The nurse identifies that a patient with delirium is at risk for injury. What interventions should be added to the patient's plan of care to address the safety concerns? Select all that apply. 1 Place a calendar within view. 2 Obtain a prescription for restraints. 3 Make sure the television is on at all times. 4 Keep the overhead lights on during the day. 5 Reorient the patient to person, place, and time as necessary.

Place a calendar within view. Reorient the patient to person, place, and time as necessary. The nurse should maintain a calm and safe environment. This includes placing a calendar within the patient's view and orienting the patient to person, place, and time as necessary. Keeping the television on at all times could be excessive environmental stimuli. Overhead lights can also contribute to excessive environmental stimuli. Restraints should be avoided.

A patient who is demonstrating signs of delirium is scheduled for a CT scan of the brain. What does the prescription for the diagnostic test suggest to the nurse? 1 An undiagnosed infection is occurring. 2 Alzheimer's disease is being ruled out. 3 Trauma to the spinal cord has occurred. 4 Potential head injury is causing the symptoms.

Potential head injury is causing the symptoms. In delirium, brain imaging studies, such as a CT scan, are used in situations in which head injury is known or suspected. A lumbar puncture would be used to aid in the diagnosis of an infection. There is no definitive diagnostic test for Alzheimer's disease. Spinal cord trauma is not associated with delirium.

A nurse is teaching a group of caregivers about how to detect the early warning signs of Alzheimer's disease. What are the warning signs that the nurse should include in the teaching? Select all that apply. 1 Problems with language 2 Disorientation to time and place 3 Memory loss that affects job skills 4 Patient requiring help with getting dressed 5 Patient requiring assistance while walking

Problems with language Disorientation to time and place Memory loss that affects job skills Frequent forgetfulness or unexplainable confusion, problems with language, and disorientation to time and place are all early warning signs of Alzheimer's disease. Most patients have trouble finding the "right" word and may forget simple words or substitute inappropriate words, making speech difficult to understand. Requiring help getting dressed or while walking may be usual in old age, owing to frailty and weakness or the presence of other musculoskeletal problems.

The nurse is preparing a plan of care to reduce an elderly patient's risk of developing delirium. What is appropriate for the nurse to include on the plan? Select all that apply. 1 Apply a vest restraint to prevent falls 2 Provide opioid pain medication as needed 3 Provide for uninterrupted sleep during the night 4 Assess for pain with every vital signs assessment 5 Ensure that eyeglasses and hearing aids are within reach

Provide for uninterrupted sleep during the night Assess for pain with every vital signs assessment Ensure that eyeglasses and hearing aids are within reach There are several factors that can precipitate or cause delirium. Opioid medication, sleep deprivation, untreated pain, sensory deprivation through vision and hearing impairment, and the use of physical restraints can precipitate delirium. To prevent the development of delirium the nurse should provide for uninterrupted sleep, assess for pain, and ensure eyeglasses and hearing aids are within reach. Opioid medication and a vest restraint should be avoided.

During a home visit the nurse suspects that an older patient who was discharged after an emergency appendectomy is demonstrating signs of delirium. Which assessment information supports the nurse's suspicion? 1 Rambling during the assessment 2 Rating pain as a 3 on a scale from 0 to 10 3 Asking for information about permitted activity 4 Requesting to have home visits in the afternoon

Rambling during the assessment Disorganized thinking exhibited by rambling is a characteristic of delirium. Delirium is one of the most frequent consequences of unscheduled surgery on the older adult, especially when the patient has not been stabilized physically or prepared emotionally. Pain level, asking for appropriate information, and discussing scheduling of home visits do not demonstrate characteristics of delirium.

Which medication helps improve memory and cognition in patients with Alzheimer's disease? 1 Sertraline 2 Trazodone 3 Haloperidol 4 Rivastigmine

Rivastigmine Rivastigmine inhibits cholinesterase, an enzyme responsible for the breakdown of acetylcholine in the synaptic cleft. It is used to treat decreased memory and cognition associated with Alzheimer's disease. Sertraline is a selective serotonin reuptake inhibitor used to treat depression associated with Alzheimer's disease. Haloperidol is an antipsychotic drug used to treat behavioral problems such as agitation and aggression that can be caused by Alzheimer's disease. Trazodone is an atypical antidepressant that may help with sleep problems associated with Alzheimer's disease.

A nurse is teaching a group of caregivers about the guidelines for caring for a patient with dementia. What are the guidelines that the nurse should include in the teaching? Select all that apply. 1 Simplify tasks for easy understanding. 2 Treat the patient with respect and dignity. 3 Give directions using gestures or pictures. 4 Remind the patient to hurry to counteract bradykinesia. 5 Mandate participation in all activities or events to counteract social withdrawal.

Simplify tasks for easy understanding. Treat the patient with respect and dignity. Give directions using gestures or pictures. For easy understanding, focus on one thing at a time. Simplifying the tasks may also help the patient in understanding them and carrying out the tasks. Treat the patient with respect and dignity, even when the patient's behavior is childlike. Respect and dignity would encourage the patient to carry out self-care activities. When taking care of a patient with dementia, do not rush or hurry the patient or force the patient to participate in activities and events; such actions can make the patient agitated.

A patient who is being treated for meningitis is diagnosed with normal pressure hydrocephalus. Which treatment does the nurse expect to be prescribed for the patient? 1 Surgery to drain the fluid 2 No treatment, because it is self-limiting 3 Corticosteroids to reduce brain swelling 4 Neurotransmitter replacement medications

Surgery to drain the fluid Normal pressure hydrocephalus is an uncommon disorder characterized by an obstruction in the flow of CSF, causing a buildup of CSF in the brain. It can be caused by meningitis. If diagnosed early, normal pressure hydrocephalus is treatable by surgery in which a shunt is inserted to divert the fluid away from the brain. The condition is not self-limiting. Because the brain is not swelling, corticosteroids are not indicated. There is no evidence to support the need to provide neurotransmitter replacement medications for normal pressure hydrocephalus.

A patient develops dementia, becomes incontinent of urine, and has difficulty walking over several months. A neurologic examination and diagnostic testing reveal that the patient has normal pressure hydrocephalus. How is this condition treated? 1 Loop diuretics such as furosemide 2 Fluid restriction and low sodium diet 3 Surgical implantation of a vagal nerve stimulator 4 Surgery with insertion of a ventricular-peritoneal shunt

Surgery with insertion of a ventricular-peritoneal shunt Normal pressure hydrocephalus occurs when the flow of cerebrospinal fluid (CSF) is blocked and builds up in the brain. The ventricles of the brain enlarge, and the patient develops neurologic symptoms. Insertion of a shunt to divert excess CSF from the ventricles to the peritoneal space lowers the pressure and corrects the neurologic symptoms. Loop diuretics and fluid restriction with a low sodium diet are used to treat fluid overload. Vagal nerve stimulators have been used to treat seizure activity.

The nurse is caring for a patient with progressive dementia who is being evaluated. Which finding supports frontotemporal lobar degeneration as the cause of the patient's symptoms? 1 Onset of dementia at age 75 2 Frequent periods of remission 3 Symmetrical atrophy of the temporal lobes 4 Improvement with anticholinergic medication

Symmetrical atrophy of the temporal lobes Frontotemporal lobar degeneration (FTLD) is a clinical syndrome associated with shrinking of the frontal and temporal anterior lobes of the brain. The major distinguishing characteristic between this disorder and Alzheimer's disease is marked symmetric lobar atrophy of the temporal and/or frontal lobes. FTLD occurs between the ages of 40 and 70. The disease progresses relentlessly and does not have periods of remission. There is no specific treatment so medications will not improve the symptoms.

Which patient is most at risk for developing delirium? a. A 50-yr-old woman with cholecystitis b. A 19-yr-old man with a fractured femur c. A 42-yr-old woman having an elective hysterectomy d. A 78-yr-old man admitted to the medical unit with complications related to heart failure

d. A 78-yr-old man admitted to the medical unit with complications related to heart failure

The nurse is providing care to several patients on a medical-surgical unit. Which patient's dementia is caused by a neurodegenerative disorder? 1 The patient with alcoholism 2 The patient with multiple sclerosis 3 The patient with Alzheimer's disease 4 The patient with uremic encephalopathy

The patient with Alzheimer's disease Alzheimer's disease is a major cause of neurodegenerative dementia. About 60 percent to 80 percent of patients with dementia are diagnosed with Alzheimer's disease. Dementia associated with alcoholism is caused by toxic, metabolic, or nutritional diseases. Dementia associated with multiple sclerosis is caused by an immunologic disease. Dementia associated with uremic encephalopathy is caused by a systemic disease.

A patient with Alzheimer's disease has difficulty eating and swallowing. What nursing interventions are appropriate to help this patient? Select all that apply. Correct 1 Use easy-grip utensils 2 Provide food in a crowded room Correct 3 Use pureed foods and thickened liquids Correct 4 Remind the patient to chew and swallow the food 5 Encourage the patient to eat while watching television

Use easy-grip utensils Use pureed foods and thickened liquids Remind the patient to chew and swallow the food The patient with Alzheimer's disease with chewing and swallowing difficulty should be offered pureed foods and thickened liquids for ease of eating. Easy-grip eating utensils may allow the patient to self-feed. Patients may need reminders to chew their food and to swallow because they tend to forget and get distracted easily. Patients need a calm and peaceful environment for eating, so meals should not be served in crowded rooms. In addition, avoid distractions, such as watching television, while eating.

An older adult patient with a history of a cardiovascular disease is undergoing treatment in a long-term care facility. Which disease is the patient most at risk of developing? 1 Delirium 2 Vascular dementia 3 Alzheimer's disease 4 Mild cognitive impairment

Vascular dementia Vascular dementia is a loss of cognitive functioning resulting from ischemic or hemorrhagic brain lesions caused by cardiovascular disease. This type of dementia is the result of decreased blood supply from narrowed and blocked arteries that supply oxygen to the brain. Alzheimer's disease is a neurodegenerative disease, and cardiovascular disease is not related to its pathogenesis. Mild cognitive impairment is a nonspecific symptom of various types of dementia, and although it is the second stage of the Alzheimer's spectrum, it is a symptom (not a disease) and is not correlated specifically with cardiovascular disease. Being of advanced age, this patient is at risk of delirium; however, delirium may not be directly caused by cardiovascular disease.

What is a major goal of treatment for the patient with AD? a. maintain patient safety. b. maintain or increase body weight. c. return to a higher level of self-care. d. enhance functional ability over time.

a. maintain patient safety.

A patient who has frontotemporal lobar degeneration has difficulty with verbal expression. What is the best advice the nurse can suggest to this patient's spouse to keep the patient safe during the day while the spouse is at work? 1 Assisted living 2 Adult day care 3 Advance directives 4 Monitor for behavioral changes

adult day care To keep this patient safe during the day while the husband is at work, an adult day care facility would be the best choice. This patient would not need assisted living. Advance directives are important but are not related to her safety. Monitoring for behavioral changes will not keep her safe during the day.

Which actions could the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) who is part of the team caring for a patient with Alzheimer's disease (select all that apply)? a. Develop a plan to minimize difficult behavior. b. Administer the prescribed memantine (Namenda). c. Remove potential safety hazards from the patient's environment. d. Refer the patient and caregivers to appropriate community resources. e. Help the patient and caregivers choose memory enhancement methods. f. Evaluate the effectiveness of the prescribed enteral feedings on patient nutrition.

b. Administer the prescribed memantine (Namenda). c. Remove potential safety hazards from the patient's environment. LPN/LVN education and scope of practice includes medication administration and monitoring for environmental safety in stable patients. Planning of interventions such as ways to manage behavior or improve memory, referrals, and evaluation of the effectiveness of interventions require registered nurse (RN)-level education and scope of practice.

The nurse is caring for a patient with variant Creutzfeldt-Jakob disease. What should the nurse suspect as the source of infection? 1 Pork 2 Beef 3 Poultry 4 Game birds

beef The infection of variant Creutzfeldt-Jakob disease is due to a prion protein acquired by eating beef from cows with bovine spongiform encephalopathy, which is also called mad cow disease. Pork, poultry, and game birds do not carry this prion, which is a small, infectious, pathogen-containing protein that lacks nucleic acid. However, variant Creutzfeldt-Jakob disease is very rare, with only a few hundred cases worldwide per decade. The type of Creutzfeldt-Jakob disease that nurses are more likely to encounter is classic Creutzfeldt-Jakob disease, whose various causes (including heredity and transplantation) are not related to beef, but even the classic type is an uncommon disease.

D.B. is admitted to a long-term care facility. He has a nursing diagnosis of impaired memory related to effects of dementia. What is an appropriate nursing intervention for him? a.let him know what behavior is socially appropriate. b.assist him with all self-care to maintain self-esteem. c.maintain familiar routines of sleep, meals, drug administration, and activities. d.promote orientation at every encounter with the patient by asking the day, time, and place.

c.maintain familiar routines of sleep, meals, drug administration, and activities.

The daughter of a patient with early familial Alzheimer's disease (AD) asks how AD is different from forgetfulness. How do you describe early warning signs of AD? a.Forgetting a colleague's name at a party b.Repeatedly misplacing car keys or a wallet c.Leaving a pot on the stove that boils dry and burns d.Having no memory of preparing a meal and forgetting to serve or eat it

d.Having no memory of preparing a meal and forgetting to serve or eat it

The child of an older patient states, "Since the discharge from the hospital two days ago, my parent won't eat and is confused." What does the nurse suspect is occurring with the patient? 1 Delirium 2 Infection 3 Dementia 4 Psychosis

delirium In most patients, delirium usually develops over a two- to three-day period. Early manifestations of delirium include loss of appetite and confusion. Loss of appetite and confusion are not indications of an infection. Dementia has a slow, insidious onset. The described manifestations are not indicative of a psychiatric disorder.

What is the leading risk factor for delirium? 1 Age 2 Dementia 3 Sleep deprivation 4 Serious medical illness

dementia The leading risk factor for delirium is dementia. Sleep deprivation has been linked to delirium, though it is not the leading risk factor. Many risk factors that can lead to delirium are more common in older patients, and older adults are more susceptible to drug-induced delirium, but age in and of itself is not a risk factor. Delirium may be a symptom of a serious medical illness.

A patient with Alzheimer's disease presents with increased vocalization and agitation. What do these symptoms indicate? 1 Pain 2 Glaucoma 3 Lack of sleep 4 Schizophrenia

pain Patients with Alzheimer's disease have cognitive impairment that may affect their oral and written language. As a result, Alzheimer's disease patients may have difficulty in expressing physical complaints, including pain. The nurse should observe for signs of pain, such as increased vocalization, agitation, withdrawal, and changes in function. Pain should be recognized and treated promptly and the patient's response monitored. Lack of sleep, glaucoma, and schizophrenia do not usually present as agitation and increased vocalization.