NCO Cognition
Which range of heart rate is acceptable for a preschooler? 60 to 100 80 to 110 75 to 100 90 to 140
80 to 110 The acceptable range for a heart rate in preschoolers is 80 to 110 beats per minute. Adults have a range of 60 to 100 beats per minute. In school-age children, the heart rate is from 75 to 100 beats per minute. The acceptable range of heart beats per minute in a toddler is 90 to 140 beats per minute.
Which manifestation is an adverse effect of intravenous lorazepam? Select all that apply. One, some, or all responses may be correct. Amnesia Drowsiness Sleep driving Blurred vision Respiratory depression
All Rationale Benzodiazepines such as lorazepam have a range of side effects, many of which are related to central nervous system depression. Anterograde amnesia, drowsiness, sleep driving, blurred vision, and respiratory depression are all potential adverse effects of lorazepam.
The nurse is caring for a toddler who has undergone bone marrow transplantation. clinical finding would the nurse anticipate if an infection develops? Fever and lethargy Positive blood antibody titers A delay in the growth of bone Neutropenia and lymphocytopenia
Fever and lethargy Rationale A fever occurs with an infection because pyrogens affect the temperature-regulating center in the hypothalamus; lethargy occurs with an infection because of the related increased basal metabolic rate. Antibody titers indicate exposure to microorganisms, not the presence of an actual infection. Delayed bone growth is not an indication of infection. After a bone marrow transplant, neutropenia and lymphocytopenia are present until the bone marrow is fully repopulated. An altered white blood cell count is not a reliable indicator of infection.
Which action would the nurse take to assess orientation to place of an older adult female who is brought to the clinic by a family member because of increasing confusion over the past week? O Ask the client to explain a proverb. O Ask the client in which state she was born. O Have the client identify the name of the clinic's town. O Have the client recall what was eaten for breakfast.
Have the client identify the name of the clinic's town. Rationale The nurse would have the client identify the name of the clinic's town. Orientation to place refers to an individual's awareness of the objective world in its relation to the self; orientation to time, place, and person is part of the assessment of cerebral functioning. Asking the client the name of the town the clinic is in assessesthis. Explaining a proverb requires abstract thinking, which involves a higher integrative function than doesorientation to place. Having the client state where the client was born helps the nurse assess remote memory,not orientation. Having the client recall what was eaten for breakfast helps assess recent memory, not orientation.
Which term describes the language pattern of a client who creates new and meaningless words as they speak? Neologism Perseveration Pressured speech Tangential speech
Neologism is the invention of new words with meanings understood only by the client. Perseveration is repetitive verbalizations or motions. Pressured speech is rapid speech with an urgent quality. Tangential speech is a tendency to digress from the original subject.
Which visual characteristic does an infant exhibit at 6 weeks of age? Select all that apply. One, some, or all responses may be correct. Binocular vision Doll's eye reflex Visual acuity 20/40 to 20/60 Peripheral vision to 180 degrees Strabismus if binocular vision is absent
Binocular vision Peripheral vision to 180 degrees Rationale Beginning at age 6 weeks, the infant has binocular vision, which becomes well established by age 4 months. Within 6 to 12 weeks, the infant has peripheral vision to 180 degrees. An infant has doll's eye reflex at birth, and it disappears within age 6 to 12 weeks. Visual acuity of 20/40 to 20/60 does not develop until age 44 to 52 weeks. Lack of binocular vision indicates strabismus at age 28 to 44 weeks. Although binocular vision generally develops by age 6 weeks, a lack of this development at this age is not indicative of strabismus.
Which is a similarity between Havighurst's stage-crisis and Erikson's psychosocial development theories? A. Both theories are based on developmental tasks. B. Both theories incorporate eight stages of development. C. Both theories are based on psychosexual development. D. Both theories emphasize that a child's growth is directed by gene activity.
A. Both theories are based on developmental tasks Both stage-crisis theory and psychosocial development theory are based on developmental tasks. Both theories teach that the successful resolution of a developmental task is essential for a successful progression through life. The stage-crisis theory has six stages whereas the psychosocial development theory has eight stages of development. Freud's theory is based on psychosexual development. Gesell's theory of development suggests that development of child is directed by gene activity.
Which atypical antipsychotic is approved for long-term use to prevent the recurrence of mood episodes in clients with bipolar disease? Select all that apply. One, some, or all responses may be correct. A. Olanzapine B. Quetiapine C. Ziprasidone D. Risperidone E. Aripiprazole
A. Olanzapine, C. Ziprasidone, E. Aripiprazole Olanzapine, ziprasidone, and aripiprazole are atypical antipsychotics approved for long-term use to prevent recurrence of mood episodes. Quetiapine and risperidone are atypical antipsychotics approved for use in bipolar disease but are not approved for long-term use to prevent the recurrence of mood episodes.
Which primary objective of nursing interventions would the nurse maintain for clients with dementia, delirium, and other neurocognitive disorders? A. Safety within the environment B. Enhancement of psychological faculties C. Participation in educational activities D. Face-to-face contact with other clients
A. Safety within the environment Safety within the environment is the primary objective of nursing interventions. Clients with neurocognitive disorders need an environment that will keep them safe, because their own abilities to interpret and respond appropriately are diminished. People with dementia, delirium, and other neurocognitive disorders usually have a declining level of function in all areas. Maintaining psychological function is often not possible. The primary objective is not to participate in education activities or have face-to-face contact with other clients. People with dementia, delirium, and other neurocognitive disorders have a limited ability to participate in educational activities and may also have a limited ability to interact socially with other clients.
Which characteristic develops in an adolescent according to Piaget's theory of cognitive development? Select all that apply. One, some, or all responses may be correct. Animism Ability to understand the process of reversibility Ability to reason with respect to possibilities Action patterns for dealing with the environment Feelings and behaviors characterized by self-consciousness
Ability to reason with respect to possibilities Feelings and behaviors characterized by self-consciousness Rationale According to Piaget's theory of cognitive development, during the formal operations stage, an adolescent develops the capacity to reason with respect to possibilities. They also show egocentrism and demonstrate feelings and behaviors characterized by self-consciousness. During the preoperational stage, a child between the ages of 2 and 7 years demonstrates animism, in which they personify objects. According to Piaget's theory, reversibility is one of the primary characteristics that develop in a child between 7 and 11 years old. Infants develop a schema or action pattern for dealing with the environment.
According to Piaget, which statement describes the concrete operation stage? A. During this stage, children have egocentric thoughts. B. During this stage, children are able to perform mental operations. C. During this stage, children learn to think with the use of symbols and mental images. D. During this stage, children develop an action pattern for dealing with the environment.
B. During this stage, children are able to perform mental operations During the concrete operation stage, children are able to perform mental operations. During the formal operations stage, there is prevalence of egocentric thoughts. During the preoperational stage, children learn to think with the use of symbols and mental images. During the sensorimotor stage, children develop an action pattern for dealing with the environment.
Which communication pattern is defined as confabulation? A. The flow of thoughts is interrupted. B. Imagination is used to fill in memory gaps. C. Speech flits from one topic to another. D. Statements are too loose to understand.
B. Imagination is used to fill in memory gaps Using imagination to fill in memory gaps is the definition of confabulation; it is a defense mechanism used by people experiencing memory deficits. Interruption of the flow of thoughts is the definition of thought blocking. Flitting from one topic to another with no apparent meaning is the definition of flight of ideas. In associative looseness, the connections between statements are so loose that only the speaker understands them.
According to Piaget's theory, which period describes a child's stage of egocentrism? A. Sensorimotor B. Preoperational C. Formal operations D. Concrete operations
B. Preoperational During the preoperational period, children learn to think with the use of symbols and mental images. They exhibit egocentrism where they see all objects and persons as their own. The sensorimotor period occurs between birth and 2 years of age. During this period, infants develop an action pattern for dealing with the environment. The formal operations period lasts from 11 years of age into adulthood. During this period, the person is self-conscious and thinks they are invulnerable and may show risk-taking behaviors. The concrete operations period occurs between 7 to 11 years of age. During this period, children are able to perform mental operations.
Which developmental skills should a preschooler exhibit? Select all that apply. One, son or all responses may be correct. A. Personal identity B. Specific reasoning C. Increased curiosity D. Magical thinking E. Understanding of others
B. Specific reasoning, C. Increased curiosity, D. Magical thinking Preschoolers begin to engage in specific and become curious. Preschoolers' thinking is often described as magical thinking. Between the ages of 12 and 36 months, toddlers start thinking of the self as separate from the mother. School-age children around the age of 12 years start concentrating on more than 1 aspect of a situation. They also start understanding different points of view.
Which period of Piaget's theory marks the end of cognitive development? A. Sensorimotor B. Preoperational C. Formal operations D. Concrete operations
C. Formal operations According to Piaget's theory, the formal operations period marks the end of cognitive development. During this period, adolescents have the capacity to reason with respect to possibilities. The sensorimotor period is the first period when a newborn develops a schema or pattern for dealing with the environment. The second period is the preoperational period when a child develops egocentrism and animism. During the concrete operations period, children are able to perform mental operations.
Which action would the nurse take for an older client with Alzheimer disease who sleeps very little and becomes more disoriented from sleep deprivation? A. Shut the client's door during the night. B. Apply a vest restraint when the client is in bed. C. Leave a dim light on in the client's room at night. D. Administer the client's prescribed as-needed sedative medication.
C. Leave a dim light on in the client's room at night. The nurse would leave a dim light on in the client's room at night. A small light in the room may prevent misinterpretation of shadows, which can heighten fear and alter the client's perception of the environment. A disoriented and confused client should be closely observed, not isolated by closing the door. Restraints are a last resort; less restrictive interventions should be used first. Sedatives should be used sparingly in older adults, because they may cause further confusion and agitation.
According to Erikson's stages of life, which is the stage of development when a child begins walking, feeding, and using the toilet? A. Trust versus mistrust B. Initiative versus guilt C. Identity versus role confusion D. Autonomy versus sense of shame and doubt
D. Autonomy versus sense of shame and doubt At 1 to 3 years of age, the child starts walking, feeding, and using the toilet on their own. This stage is one of autonomy versus sense of shame and doubt. The stage from birth to 1 year when the infant develops trust toward the parent or the caregiver is known as the trust versus mistrust stage. The initiative versus guilt stage is marked by the child's fantasies and imaginations motivating the child to explore their environment. The identity versus role confusion stage begins after adolescence. During this stage, the adolescent aims to find their identity.
Which strategy would the nurses use to minimize aggressive behaviors from the client with a neurocognitive disorder? A. Limit the time staff and the client spend together. B. Follow an outline of consequences for uncooperative behavior. C. Use the client's preferences as a reward or a punishment. D. Identify nursing staff members whom the client prefers.
D. Identify nursing staff members whom the client prefers The strategy is to identify nursing staff members whom the client prefers. The type of care needed by the client requires trust in the caregiver, which develops more rapidly when there is a cooperative relationship and client input is accepted. Limiting staff time may place the client in jeopardy. The staff should not be put in the position of punishing the client; the client with neurocognitive disorder cannot be held responsible for uncooperative behavior. Clients with neurocognitive disorder will not remember and learn from a reward system.
Which strategy would the nurse include in a plan of care for a client with Alzheimer disease: Implement remotivational therapy. Structure the environment for safety. Arrange for long-term custodial care. Stimulate thinking with new experiences.
Structuring the environment for safety supports the client's ability to function in a protected, safe milieu. Attempting to remotivate the client is not the priority; also, it is not always possible to remotivate a client with Alzheimer disease. There are no data to indicate that the client needs long-term custodial care at this time. Structure and routines will decrease anxiety and increase performance of activities of daily living; whereas, stimulating thinking with new experiences would be too overwhelming for a client with Alzheimer disease. Cognitive maintenance should be part of the focus of care.
A client with dementia is confused about what day it is. Which statement made by the nurse is an example of validation therapy? "No, try to be in your sense of reality." "Yes, today is the day that you just mentioned." "You should try improving your awareness level." "Try to recall your past memories associated with the day."
"Yes, today is the day that you just mentioned." Rationale Validation therapy is an approach to communication with a confused client with dementia. In this approach, the nurse accepts the description of the time and place as stated by the client. The statement "Yes, today is the day that you just mentioned" represents the use of validation therapy. Asking the client to reorient to reality and asking the client to improve awareness level are examples of the reality orientation approach. Reminiscence is an approach that asks the client to recall past experiences.
Which medication is associated with sedation as a side effect? Select all that apply. One, some, or all responses may be correct. Doxepin Zalepion Suvorexant Nefazodone Mirtazapine Clonazepam
-All Doxepin is a low-dose formulation of an old tricyclic antidepressant that is indicated for the treatment of insomnia. Zaleplon is a Z-hypnotic often prescribed for insomnia. Suvorexant is an orexin receptor agonist that can cause daytime sleep and sleep paralysis. Nefazodone is a serotonin blocker indicated for depression that causes sedation. Mirtazapine blocks adrenergic receptors to improve sleep. The most common side effects are sedation and weight gain. Clonazepam is a benzodiazepine. All benzodiazepines can cause sedation at higher therapeutic doses.
The nurse notices an infant has developed a color preference for red and yellow. Which should be the likely age of the infant? 4 weeks 8 weeks 15 weeks 20 weeks
20 weeks Rationale An infant develops a color preference for yellow and red between 20 to 28 weeks of age. At 4 weeks, the infant can follow a range of 90 degrees. Between 6 to 12 weeks of age, the infant develops peripheral vision to 180 degrees. Between 12 to 20 weeks of age, the infant is able to accommodate to near objects.
Which of these statements about language development in children ages 12 to 36 months are true? Select all that apply. One, some, or all responses may be correct. 24-month-old children use pronouns. 18-month-old children use approximately 25 words. 24-month-old children speak in four-word sentences. 24-month-old children have a vocabulary of up to 500 words. 36-month-old children learn to use five or six new words each day.
24-month-old children use pronouns. 36-month-old children learn to use five or six new words each day. Rationale Children 24 months old use pronouns and want independence and control. By 36 months, children can use simple sentences and follow some grammatical rules and are learning to use five or six new words each day. Children 18 months old use approximately 10 words. Children 24 months old speak in two-word sentences drawn from a vocabulary of up to 300 words.
By which age is a child expected to understand the concept of conservation of numbers for the first time? 5 years 7 years 9 years 12 years
5 years Rationale There is a developmental sequence in children achieving milestones in understanding the capacity to conserve matter. Children usually grasp conservation of numbers between the ages of 5 and 6 years. Conservation of liquids, mass, and length usually is accomplished at apout ages 6 to 7 years old. Conservation of weight is understood sometime later, around ages 9 to 10 years old. The child begins to understand conservation of volume or displacement last, between ages 9 and 12 years old.
Which characteristic about confusion would the nurse keep in mind when an older client with Alzheimer disease is admitted to a long-term care facility? Occurs with a transfer to new surroundings Will be unchanged despite reality orientation Is a common finding and expected with normal aging Results from brain changes that make interventions futile
A change in environment and introduction of unfamiliar stimuli precipitate confusion in clients with Alzheimer disease; with appropriate intervention, confusion can be reduced. Reality orientation can reduce confusion when these clients are confronted with unfamiliar surroundings. Although confusion may be a common finding in Alzheimer disease, it is not expected with normal aging. Although brain changes do occur with Alzheimer disease, interventions can be instituted to decrease confusion.
Which belief would the nurse expect a preschooler to hold regarding the concept of death? A temporary condition Results from certain illnesses Something that happens in the hospital An event that eventually happens to everyone
A temporary condition Rationale Preschoolers do not have the cognitive ability to understand that death is irreversible. Preschoolers are unable to make logical connections between cause and effect. If a family member died in the hospital, the preschooler might believe that death happens in the hospital; however, this is not a predominant belief. Preschoolers do not have an understanding of the inevitability of death.
Which period of Piaget's theory describes the idea of object permanence? A. Sensorimotor period B. Preoperational period C. Formal operations period D. Concrete operations period
A. Sensorimotor period There are four periods of Piaget's theory of cognitive development. The first period is the sensorimotor period; this period describes object permanence. During the ages of birth to 2 years, the child develops the understanding that objects continue to exist even when they are not visible. The second period is the preoperational period, which is observed in children between the ages of 2 and 7 years. During this time, children begin to use symbols and has the ability to pretend. The third period is the concrete operations period, which is observed between the ages of 7 and 11 years. During this period, the child is able to think logically about concrete events. The formal operations period is the fourth period, which is observed in youth from the ages of 11 years old throughout adulthood. During this period, there is a prevalence of egocentric thought and the individual is able to use abstract thought.
Which factor is unique to vascular dementia when comparing assessment findings in clients with vascular dementia and dementia of the Alzheimer type ? Memory impairment Abrupt onset of symptoms Difficulty making decisions Inability to use words to communicate
Abrupt onset of symptoms Rationale The signs and symptoms associated with vascular dementia have an abrupt onset (days to weeks) because of the occlusion of small arteries or arterioles in the cortex of the brain. Dementia of the Alzheimer type is associated with a gradual (years), progressive loss of function. Memory impairment and difficulty making decisions may or may not be a symptom of vascular dementia; it depends on which part of the brain is affected. Alzheimer disease usually results in memory impairment and difficulty with decision-making, but not abruptly. Inability to use words to communicate is a typical symptom of Alzheimer disease, but with vascular dementia, the client may have trouble speaking or understanding speech.
Which description is correct for Alzheimer disease? Emerges in the fourth decade of life Is a slow, relentless deterioration of the mind Is functional in origin and occurs in the later years Is diagnosed through laboratory and psychological tests
Alzheimer disease is a slow and relentless deterioration of the mind; clients become progressively worse over time. The disease usually appears in people 60 years of age and older. Alzheimer disease is an organic, not a functional, disorder. Diagnostic tools, such as compyted tomography scan or positron emission tomography, are used to rule out conditions (e.g., neoplasms), and psychological tests such as the Mini-Mental State Examination are used to determine cognitive decline; however, there are no tests that give a definite confirmation of Alzheimer disease.
Which problem would the nurse anticipate when working with a client who has a phobia of black cats? Denying that the phobia exists Anger toward the feared object Anxiety when discussing the phobia Distortion of reality when completing daily routines
Anxiety when discussing the phobia Rationale Discussion of the feared object triggers anxiety and an emotional response to the object. People with phobias generally acknowledge their existence. Extreme fear is more of a problem than anger. Although the client may avoid situations to avoid black cats, distortion of reality (psychosis) related to the daily routine usually is not a problem for a person with a phobia.
Which mental process would be recognized by the nurse as associated with deterioration that accompanies aging? Judgment Intelligence Creative thinking Short-term memory
Short-term memory During the aging process there is a progressive atrophy of the convolutions of the brain with a decrease blood supply, which may produce a tendency to become forgetful, a reduction in short-term memory, an susceptibility to personality changes. There should be little or no change in judgment. There is little or no intellectual deterioration; intelligence scores show no decline. Creativity is not affected by aging; many people remain creative until very late in life.
Which nursing intervention would the nurse take for an older adult with delirium who begins acting out while in the dayroom? a. Instructing the client to be quiet b. allowing the client to act out until fatigue sets in c. immediately guiding the client from the room by gently holding the client's arm d. giving the client one simple direction at a time in a firm low pitch voice
d. giving the client one simple direction at a time in a firm low pitch voice
Which psychosocial developmental skill would the nurse anticipate in a 4-year-old child? Self-evaluation Logical thinking Increased curiosity Understanding of others
Increased curiosity Rationale The nurse will notice that the 4-year-old child is curious about their surroundings and wants to make new friends. School-aged children begin to define their self-concept and develop self-esteem, an overall self- evaluation. School-aged children have the ability to think in a logical manner about the here and now and to understand the relationship between things and ideas. At around the age of 12 years, children start concentrating on more than one aspect of a situation. They also start understanding the point of view of other people.
Which action would the nurse take for an older client with Alzheimer disease who has laid out several outfits on the bed to wear to a recreational session but is still wearing nightclothes? A. Assist the client to dress and explain when residents are expected at the activity. B. Prompt the client to dress more quickly to avoid delaying the other residents. C. Help the client select appropriate attire and offer to help the client get dressed. D. Allow the client time to dress but explain that the client has missed the opportunity to attend the activity.
C. Help the client select appropriate attire and offer to help the client get dressed Helping the client select appropriate attire and offering help in getting dressed is the action the nurse would take. This aids the client in decision-making; new situations may be stressful and may lead to ambivalent feelings. Assisting the client to dress and explaining when residents are expected at the activity is not sharing decision-making; the client may not remember this explanation in the future. Reminding the client to dress more quickly to avoid delaying the other residents may make the client more anxious and frustrated. Because of Alzheimer disease, the client needs help, not punishment, for getting dressed to attend an activity.
According to the Piaget's theory, which behavior would be expected in a 9-year-old child? Logical reasoning Concrete thinking Object permanence Imaginary audience
Concrete thinking A child of 9 years of age will exhibit concrete thinking. Logical reasoning is observed in individuals starting from the age of 11 years. Object permanence is observed in children between birth and 2 years old. The idea of being constantly observed by an imaginary audience is observed in individuals starting from the age of 11 years.
An older adult seems to make up stories to fill in for memory lapses. Which behavior is client displaying? Lying Denying Fantasizing Confabulating
Confabulation is the filling in of memory gaps as a protective mechanism. Lying is false or dishonest behavior that is conscious and deliberate and is used in an attempt to deceive or mislead. Denying is a refusal to believe or accept reality and is used as a protective defense mechanism. Fantasizing is a more-or-less connected series of mental images, such as those that occur in daydreams, that usually involve some unfulfilled desire.
A client is diagnosed with Alzheimer disease and is exhibiting hyperorality. Which parameter would the nurse closely monitor to keep this client safe? For choking at meal times For the presence of mouth ulcers For injuries from touching hot foods For attempts at eating inedible objects
For attempts at eating inedible objects Rationale The nurse would closely monitor for attempts at eating inedible objects. Hyperorality is the compulsive need to taste, chew, and put everything in the mouth. Hyperorality is not related to choking at meal times; dysphagia is related to choking. Hyperorality is not related to mouth ulcers; stomatitis refers to mouth ulcers. Injuries from touching refers to hypermetamorphosis, the urge to touch everything.
Which finding would the nurse observe in a child with autism spectrum disorder? Interest in music Outgoing behavior Attachment to friends Responsiveness to the parents
Interest in music Rationale The child would have an interest in music. Music is nonthreatening, comforting, and soothing for a child with autism spectrum disorder. The autistic child does not have an outgoing behavior; the child is usually withdrawn. There is a lack of attachment to people/friends but the child may have attachments to objects. The nurse would not observe responsiveness to the parents in this child. One of the symptoms an autistic child displays is a lack of responsiveness to others or parents; there is little or no extension to the external environment.
Which action would the nurse take for an older client with Alzheimer disease who sleeps very little and becomes more disoriented from sleep deprivation? Shut the client's door during the night. Apply a vest restraint when the client is in bed. Leave a dim light on in the client's room at night. Administer the client's prescribed as-needed sedative medication.
Leave a dim light on in the client's room at night Rationale The nurse would leave a dim light on in the client's room at night. A small light in the room may prevent misinterpretation of shadows, which can heighten fear and alter the client's perception of the environment. A disoriented and confused client should be closely observed, not isolated by closing the door. Restraints are a last resort; less restrictive interventions should be used first. Sedatives should be used sparingly in older adults, because they may cause further confusion and agitation.
Which nursing intervention would the nurse consider the highest priority for a client who was in a motor bike accident and has a severe neck injury? Assessing for crepitus Assessing for bleeding Maintaining a patent airway Performing neurological assessment
Maintaining a patent airway Rationale The nurse should assess, ensure, and maintain a patent airway first in a client with neck trauma. The nurse then may palpate the skin near the esophagus to assess crepitus, which indicates an injury to the esophagus After ensuring airway patency, the nurse should assess for bleeding or impending shock. The nurse should also perform a neurological assessment for mental status, sensory level, and motor function, which holds a medium priority.
Which factor would precipitate a client's use of confabulation? Ideas of grandeur Need for attention Marked memory loss Difficulty in accepting the diagnosis
Marked memory loss Marked memory loss precipitates a client's use of confabulation. A client with this disorder has a loss of memory and adapts by filling in areas that cannot be remembered with made-up information. Ideas of grandeur do not precipitate use of confabulation. The use of confabulation is not attention-seeking behavior; the individual is attempting to mask memory loss. The individual uses confabulation as an attempt to mask memory loss, not because of difficulty in accepting the diagnosis.
A client with hepatic cirrhosis begins to exhibit slurred speech, confusion, drowsiness, and a flapping tremor. Based upon this assessment, which prescribed diet would the nurse anticipate? No protein Moderate protein High protein Strict protein restriction
Moderate protein Rationale Because the liver is unable to detoxify ammonia to urea and the client is experiencing clinical manifestations leading to an impending hepatic encephalopathy coma, protein intake should be moderate. Strict protein and no-protein restrictions are not required because the client needs protein for healing. The hepatic encephalopathy diagnosis contradicts high-protein intake because protein breaks down into ammonia.
Which is the priority nursing action for a child with severe burns on the arms and who is scheduled for therapeutic escharotomy? Removing blisters Monitoring radial pulses Maintaining airborne precautions Performing passive range-of-motion exercises
Monitoring radial pulses. Eschar is rigid and may restrict circulation and lead to loss of limb perfusion. Blisters are associated with superficial and deep partial-thickness burns; eschar is associated with full-thickness burns. Blisters are not removed because they protect the underlying skin. Maintaining airborne precautions is unnecessary; the client is not the source of infection but must be protected from infection because the first line of defense has been compromised. Performing passive range-of-motion exercises is unnecessary.
Which is a primary contributing factor for the risk-taking behavior for school-aged children? Peer pressure Cognitive ability Chronological age Developmental stage
Peer pressure Rationale Peer pressure is a normal part of psychological development, but it is also a major contributing factor to risk-taking behaviors. Cognitive ability, chronological age, and developmental stage are not the primary contributing factors to risk-taking behaviors in school-age children.
Which action would the nurse encourage the daughter of a client diagnosed with early Alzheimer disease to do to best address the functional and behavioral changes associated with this this disease? Place the client in a long-term care facility. Provide for the client's basic physical needs. Post a schedule of the client's daily activities. Perform care so the client does not need to make decisions.
Post a schedule of the client's daily activities. Rationale The nurse would tell the daughter to post a schedule of the client's daily activities. In early Alzheimer disease, clients have mild cognitive impairment with short-term memory loss; establishing a daily routine, posting it, and adhering to it provides a concrete, structured approach. Placing the client in a long-term care facility may be required later if the daughter is unable to cope with the client's functional and behavioral changes. In the early stages, clients can provide for their own basic activities of daily living such as bathing, dressing, and eating. Clients can make simple decisions in early Alzheimer disease, and they have the right to make choices; an authoritarian approach may promote regression, anxiety, depression, or anger.
Which stage of Piaget's theory of cognitive development would the nurse observe in a preschooler? Sensorimotor Preoperational Formal operations Concrete operations
Preoperational Rationale The second stage of Piaget theory of cognitive development is the preoperational stage. It is observed from 2 to 7 years. During this stage, the child may learn to think with the use of symbols and mental images. The first stage is the sensorimotor stage, observed from birth to 2 years. During this stage, the child learns about self and the environment through motor and reflex actions. The fourth stage is formal operations, characterized by a prevalence of egocentric thought. The concrete operations stage is stage 3, which signifes that the child is able to perform mental operations.
Which cognitive developmental milestone is characteristic of preschoolers? Preschoolers do not fear bodily harm. Preschoolers are aware of cause-and-effect relationghips. Most rapid growth occurs in the temporal lobes of the brain. Preschoolers are unable to classify objects according to size.
Preschoolers are aware of cause-and-effect relationghips Rationale During the learning process, preschoolers start relating things. They become aware of cause-and-effect relationships. For example, they may think, 'The sun sets because people want to go to bed.' The greatest fear of preschoolers is bodily harm. This is evident in children's fear of the dark, animals, thunderstorms, and medical personnel. The most rapid growth is seen in the frontal lobes during brain maturation. Organizing new activities and maintaining attention to tasks are paramount. Preschoolers demonstrate their complex thinking abilities by classifying objects according to size or color and by questioning.
Which method would the nurse expect to be used successfully with a client who has a phobia about closed spaces? Desensitization Contracting Role playing Assertiveness training
Rationale Desensitization is a method that is used successfully with a client who has phobias. Contracting, role playing, and assertiveness training are all useful general behavioral approaches, but these types of techniques are not as successful as desensitization.
Which medications would the nurse identify as used to treat generalized anxiety disorder (GAD)? Select all that apply. One, some, or all responses may be correct. Duloxetine Venlafaxine Clonazepam Escitalopram Clomipramine
Rationale Duloxetine, venlafaxine, and escitalopram are antidepressants approved for the treatment of GAD. Clonazepam and clomipramine are used to treat panic disorders.
Which symptom in an older adult would require an immediate reassessment of the client's needs and plan of care? Memory loss or confusion Neglect of self-care Increased daily fatigue Withdrawal from usual
Rationale Memory loss or confusion would require an immediate reassessment. All are common signs of depression due to the aging process; however, memory loss or confusion requires immediate intervention. The development of confusion indicates that the client's ability to maintain equilibrium has not been achieved and that further disequilibrium is occurring, setting the client up for safety issues. Confusion may also be related to more serious physical conditions that can occur which require medical intervention. Although neglect of self-care can occur, it is not the immediate need. Although increased daily fatigue is important, it does not require immediate follow-up. It is common for clients with depression to withdraw from usual activities, so it does not need immediate reassessment.
Which medication is indicated to treat shift-work sleep disorder (SWSD)? Caffeine Modafinil Atomoxetine Methylphenidate
Rationale Modafinil is a unique nonamphetamine stimulant used to treat SWSD. This medication promotes wakefulness in clients suffering from excessive sleepiness associated with SWSD. Caffeine is a central nervous stimulant used to promote wakefulness, but this medication is not as effective in the treatment of SWSD. Atomoxetine is a nonstimulant used to treat attention-deficit/hyperactivity disorder (ADHD). Methylphenidate is considered a first-choice medication for the treatment of ADHD.
Which atypical antipsychotic is approved for long-term use to prevent the recurrence of mood episodes in clients with bipolar disease? Select all that apply. One, some, or all responses may be correct. Olanzapine Quetiapine Ziprasidone Risperidone Aripiprazole
Rationale Olanzapine, ziprasidone, and aripiprazole are atypical antipsychotics approved for long-term use to prevent recurrence of mood episodes. Quetiapine and risperidone are atypical antipsychotics approved for use in bipolar disease but are not approved for long-term use to prevent the recurrence of mood episodes.
Which information would the nurse use to explain a positive diagnosis for human immunodeficiency virus (HIV) infection? Performance of high-risk sexual behaviors Evidence of extreme weight loss and high fever Identification of an associated opportunistic infection Positive enzyme-linked immunosorbent assay (ELISA) and Western blot tests
Rationale Positive ELISA and Western blot tests confirm the presence of HIV antibodies that occur in response to the presence of the HIV. Performance of high-risk sexual behaviors places someone at risk but would not constitute a positive diagnosis. Evidence of extreme weight loss and high fever do not confirm the presence of HIV; these adaptations are related to many disorders, not just HIV infection. The diagnosis of just an opportunistic infection is not sufficient to confirm the diagnosis of HIV. An opportunistic infection (included in the Centers for Disease Control and Prevention surveillance case definition for acquired immunodeficiency syndrome (AIDS]) in the presence of HIV antibodies indicates that the individual has AIDS.
Which technique would be appropriate for clients who exhibit mild neurocognitive impairment? Reality orientation Behavioral confrontation Reflective communication Reminiscence group therapy
Rationale Reality orientation is a technique to use with clients who have mild neurocognitive impairments. Reality orientation is generally helpful for clients exhibiting mild neurocognitive impairment; these clients are aware of their impairment, and orientation then reduces anxiety. Behavioral confrontation is not therapeutic because it may cause frustration and increase psychomotor agitation in a client with neurocognitive impairment. Reflective communication is a technique in which the nurse restates or repeats the client's statements; it can be used to clarify thoughts but may also lead to frustration when the approach is overdone. Reminiscence group therapy is helpful with moderate to severe neurocognitive impairments because it reinforces identity and acknowledges what was significant.
Which information would the nurse include in family teaching regarding the client's use of confabulation? The client is fantasizing about past experiences. This indicates poor control over disorganized thoughts. The client is making up what cannot be remembered. This indicates opposing feelings are occurring simultaneously.
Rationale The client will make up what cannot be remembered when using confabulation. Confabulation is a deliberate face-saving defense wherein stories are made up to fill in gaps and disguise memory loss. A client does not fantasize when confabulating. Having poor control over disorganized thoughts reflects loose associations, not confabulation. Experiencing opposing feelings simultaneously is ambivalence, not confabulation.
Which nursing objective would be essential for a client who is demonstrating manic-type behavior by being demanding and hyperactive? To ease the client's feelings of guilt To maintain a supportive, structured environment To point out reality through continued communication To broaden the client's contacts with other people on the unit
Rationale The essential objective is to maintain a supportive, structured environment. These clients are acutely aware of and sensitive to the environment; they need a structured environment in which stimuli are minimized and a feeling of acceptance and support is present. Lessening the client's feelings of guilt is a vague objective; it is not measurable. Pointing out reality through continued communication is not essential. Reality orientation is not needed as much as maintaining a safe structured environment. The client needs minimal, not increased, stimuli. The stimuli would be increased by broadening the client's contacts with other people.
According to Erikson's theory, at which stage does a child start to have fantasies and an active imagination? Trust versus mistrust Initiative versus guilt Identity versus role confusion Autonomy versus sense of shame and doubt
Rationale The initiative versus guilt stage is characterized by a child having fantasies and imaginations that motivate the child to explore their environment. The stage from birth to 1 year old when an infant develops trust toward their parent or caregiver is known as the trust versus mistrust stage. The identity versus role confusion stage begins after adolescence; during this stage, an individual tries to figure out their own identity. Between the ages of 1 to 3 years old, a child starts walking, feeding, using the toilet, and handling some basic self-care activities. This stage is one of autonomy versus sense of shame and doubt.
Which intervention would the nurse include in the plan of care for a client with moderate Alzheimer disease? Discuss recent current events. Teach the client new social skills. Maintain a daily routine of living. Encourage new activities daily.
Rationale The nurse would include the intervention to maintain a daily routine of living. The client with this disorder will be most comfortable with a familiar and repetitive daily routine because it will produce less anxiety. Cognitive changes probably make a discussion of current events unrealistic. It probably is beyond the client's capability to develop new social skills. Encouraging new activities daily can increase anxiety and agitation in clients who have moderate Alzheimer disease.
Which complication would the nurse consider in a client who just had a total hip replacement and is experiencing restlessness and changes in mentation? Bladder spasms Polycythemia vera Hypovolemic shock Pulmonary hypertension
Rationale These signs occur with hypovolemic shock because less blood is being circulated to vital centers in the brain. A large loss of blood may occur during and after orthopedic surgery. Urinary retention, not bladder spasms, may occur after general anesthesia. Anemia and deep vein thrombosis, not an increase in the total red blood cells (polycythemia vera), tend to occur after a total hip replacement. Atelectasis and pneumonia are possible complications of general anesthesia, but pulmonary hypertension is not a postoperative complication.
Which need would be essential in clients who have dementia? To relate in a consistent manner to staff To learn that the staff cannot be manipulated To accept controls that are concrete and fairly applied To have sameness and consistency in the environment
Rationale To have sameness and consistency in the environment is a need that is essential in clients with dementia. A consistent approach and consistent communication from all members of the health team help the client who has dementia remain more reality oriented. It is the staff members who need to be consistent, not the client's need. Clients who have this disorder do not attempt to manipulate the staff. Acceptance of controls that are concrete and fairly applied is not an essential need from clients who have this disorder; consistency is most essential.
Which parameters would the nurse consider for proper rapid baseline assessment using a disability mnemonic (AVPU) in a client with drug abuse? Select all that apply. One, some, or all responses may be correct. Level of anxiety Reaction to pain Response to voice Body temperature Evidence of assault
Reaction to pain Response to voice Rationale The disability examination provides a rapid baseline assessment of neurological status. It helps evaluate level of consciousness by the AVPU mnemonic, which also helps assess the responsiveness to pain and voice. Level of anxiety is not assessed by a disability mnemonic. Body temperature and evidence of assault are assessed in a primary survey of exposure.
Which topic addressed by a new nurse when talking with a client who has neurocognitive disorder due to Lewy bodies would cause the charge nurse to follow-up? Married life Work years Recent days Young adulthood
Recent days Rationale The charge nurse would follow-up if the new nurse talked about recent days. Neurocognitive disorder due to Lewy bodies is characterized with short-term memory loss, unpredictable cognitive shifts, and sleep disturbances. Thus talking about recent days would be ineffective. Memories of remote events (e.g., married life, working years, young adulthood) usually remains fairly intact. Therefore the charge nurse would not have to follow-up when the new nurse talked to the client about these topics.
Which concept of death would the nurse expect a 4-year-old child to have? Cessation of life Reversible separation Only affects old people Force takes one away from family
Reversible separation Rationale Preschoolers view death as a separation; they believe that the deceased will return to life. This is part of their fantasy world; they view death as a kind of sleep rather than a cessation of life and expect the deceased to return or wake up. The preschooler does not yet have the understanding that older people are more likely to die. The preschooler believes that the separation was initiated by the deceased, not by another force.
Which characteristic of a therapeutic milieu would the nurse consider important for a confused older adult with socially aggressive behavior? O Sets limits O Has variety O Is group oriented O Allows freedom of expression
Sets limits Rationale The therapeutic milieu characteristic would be to set limits. Because clients with socially aggressive behavior have poor control, these individuals require a therapeutic environment in which appropriate limits for behavior are set for them. Variety will increase anxiety. The daily routine should be structured and repetitive. A group-oriented environment is too stimulating for a person with socially aggressive behavior. Freedom of expression may result in injury to the client or others, because the client may be unable to control impulses.
Which factor is associated with the aging process? Slowing of responses Change of personality Loss of intelligence Loss of long-term memory
Slowing of responses Rationale Neurological responses are slowed because of reduced sensory-receptor sensitivity. Excluding pathological processes, the personality will be consistent with that of earlier years. There is no loss of intellectual ability unless there is a pathological problem. Short-term, not long-term, memory is reduced because of a shortened attention span, delayed transmission of information to the brain, and perceptual deficits.
A toddler is able to recognize the shapes of objects and fit smaller boxes into larger boxes, Which type of cognitive development would this action indicate? Domestic mimiery Causal relationship Spatial relationship Object permanence
Spatial relationship Rationale The toddler's ability to recognize the shapes of objects and fit smaller boxes in larger boxes indicates awareness of spatial relationships. If the toddler is acutely aware of others' actions and attempts to copy them in gestures and words, it indicates domestic mimicry. When the toddler explores an object each time it appears in a new place, it indicates an awareness of causal relationships. If the toddler understands that objects continue to exist even when they cannot be observed in the same place, it indicates an awareness of object permanence.
Which assessment finding is associated with depression? O The client has islands of intact memory. O The client has impaired recent and remote memory, O The client has impaired recent and immediate memory, O The client needs step-by-step instructions for simple tasks.
The client has islands of intact memory. Rationale Depression may occur with major changes in life. A client with depression has selective or patchy memory loss with islands of intact memory. A client with dementia has impaired recent and remote memory. The onset of delirium may be abrupt, causing impaired recent and immediate memory. A client with delirium is forgetful and requires step-by-step instructions to complete simple tasks.
Which intervention would the nurse include in the nursing home plan of care for an older adult with Alzheimer disease who has nighttime wandering? Order a vest restraint for the client to be applied at night. Obtain a prescription for a sedative so the client will sleep better at night. Request that the family provide a companion to stay with the client at night. Assign the client to a room near the nurses' station for closer supervision at night.
The nurse would assign the client to a room near the nurse's station for closer supervision at night because the client has nighttime wandering. It is the nurse's responsibility to ensure the safety of clients; close supervision can help ensure that the client does not wander. Restraints should not be used without a primary health care provider's order; a restraint is too excessive an intervention to prevent wandering. The issue is not that the client does not sleep; the issue is that the client wanders, and sedatives can increase confusion in older adult clients. It is the responsibility of the facility (not the family), specifically the nurse, to meet the needs of and ensure the safety of clients.
Which intervention would the nurse include when developing a plan of care for an older client with dementia? a. Explain to the client the details of the regimen. b. Demonstrate interest in the client's various likes and dislikes. c. Be firm when dealing with the client's attitudes and behaviors. d. Provide consistency in carrying out nursing activities for the client.
d. Provide consistency in carrying out nursing activities for the client The nurse would include providing consistency in carrying out nursing activities for the client. Familiarity with situations and continuity add to the client's sense of security and foster trust in the relationship. Detailed explanations will be forgotten; instructions should be simple and to the point and given when needed for clients with dementia. Although demonstrating interest in the client's likes and dislikes helps individualize care, in a client with dementia likes and dislikes may be hard to remember. Being firm when dealing with the client's attitudes and behaviors may increase anxiety in the client with dementia; some degree of flexibility by the nurse helps decrease outburst from clients with dementia.
