Nursing Care of Clients with Disorders Related to Alterations in Cognition and Perception

170. What is an important aspect of nursing care for a client exhibiting psychotic patterns of thinking and behavior? 1. Help keep the client oriented to reality. 2. Involve the client in activities throughout the day. 3. Help the client understand that it is harmful to withdraw from situations. 4. Encourage the client to discuss why interacting with other people is being avoided.

1 Keeping the withdrawn client oriented to reality prevents further withdrawal into a private world

169. What is the best nursing intervention to encourage a withdrawn, noncommunicative client to talk? 1. Focus on nonthreatening subjects. 2. Try to get the client to discuss feelings. 3. Ask simple questions that require "yes" or "no" answers. 4. Sit quietly while looking through magazines with the client.

1 Nursing care involves a steady attempt to draw the client into some response. This can best be accomplished by focusing on nonthreatening subjects that do not demand a specific response.

140. What is the most appropriate nursing intervention for clients who exhibit mild cognitive impairment? 1. Reality orientation 2. Behavioral confrontation 3. Reflective communication 4. Reminiscence group therapy

1 Reality orientation generally is helpful to clients exhibiting mild cognitive impairment; these clients are aware of their impairment, and orientation then reduces anxiety.

126. A client with dementia has been cared for by the spouse for 5 years. During the last month the client has become agitated and aggressive and is incontinent of urine and feces. What is the priority nursing care while this client is in an inpatient mental health facility? 1. Managing the behavior 2. Preventing further deterioration 3. Focusing on the needs of the spouse 4. Establishing an elimination retraining program

1 The client must be kept from harming self or others; the client needs a calm, supportive environment that meets needs and maintains dignity.

162. A nurse observes a regressed, emotionally disturbed client using the hands to eat soft foods. What is the best nursing intervention? 1. Give the client a spoon and suggest it be used. 2. Say in a joking way, "Well, I guess fingers were made before forks." 3. Ignore the behavior and observe several additional meals before intervening. 4. Remove the food while saying, "You can't have any more until you use your spoon."

1 The client needs limits to be set. This response sets limits and rejects the behavior but accepts the client

150. An acutely ill client with the diagnosis of schizophrenia has just been admitted to the mental health unit. What is the most therapeutic initial nursing intervention? 1. Spend time with the client to build trust and demonstrate acceptance. 2. Involve the client in occupational therapy and use diversional activity. 3. Delay one-to-one client interactions until medications reduce the psychotic symptoms. 4. Involve the client in multiple small-group discussions to distract attention from the fantasy world.

1 The initial intervention should be to demonstrate acceptance and work toward developing trust.

160. A client experiencing hallucinations tells a nurse, "The voices are telling me I'm no good." The client asks whether the nurse hears the voices. Which is the nurse's most appropriate response? 1. "No, I do not hear the voices, but I believe you can hear them." 2. "It is the voice of your conscience, which only you can control." 3. "Those voices are coming from within you; only you can hear them." 4. "Hearing the voices are a symptom of your illness; don't pay attention to them."

1 The nurse, demonstrating knowledge and understanding, accepts the client's perceptions even though they are hallucinatory

164. While watching TV in the day room, a client who has demonstrated withdrawn, regressed behavior suddenly screams, bursts into tears, and runs out of the room to the far end of the hallway. What is the most therapeutic action by the nurse? 1. Walk to the end of the hallway where the client is standing. 2. Accept the action as being the impulsive behavior of a sick person. 3. Ask another client in the day room why the client acted as she did. 4. Document the incident in the client's record while the memory is fresh.

1 This lets the client know that the nurse is available. It also demonstrates an acceptance of the client.

151. A client with schizophrenia plans an activity schedule with the help of the treatment team. A written copy is posted in the client's room. What should the nurse say when it is time for the client to go for a walk? 1. "It's time for you to go for a walk now." 2. "Do you want to take your scheduled walk now?" 3. "When would you like to go for your walk today?" 4. "You are supposed to be going for your walk now."

1 This message is concise and does not require decision making; it is less likely to increase anxiety.

147. One evening a nurse finds a client who has been experiencing persecutory delusions trying to get out the door. The client states, "Please let me go. I trust you. The Mafia is going to kill me tonight." Which response is most therapeutic? 1. "You are frightened. Come with me to your room, and we can talk about it." 2. "Come with me to your room. I'll lock the door, and no one will get in to harm you." 3. "Nobody here wants to harm you, and you know that. I'll come with you to your room." 4. "Thank you for trusting me. Maybe you can trust me when I tell you no one will kill you here."

1 This response recognizes the client's feelings and provides assurance that the staff member will be present.

154. A client with a history of schizophrenia attends the mental health clinic for a regularly scheduled group therapy session. The client arrives agitated and exhibits behaviors that indicates the hearing of voices. When a nurse begins to walk toward the client, the client pulls out a large knife. Which is the nurse's best approach? 1. Firm 2. Passive . Empathetic 4. Confrontational

1 A firm approach prevents anxiety transference and provides structure and control for a client who is out of control.

171. Why is observation an especially important aspect of nursing care for a withdrawn client? 1. It assists in confirming the client's diagnosis. 2. It helps in understanding the client's behavior. 3. The staff is informed about the client's illness. 4. The degree of the client's depression is indicated.

2 By observing the client the nurse is better able to understand the client's behavior, which can be an indication of feelings.

156. As a nurse enters a room and approaches a client who has schizophrenia, the client states, "Get out of here before I hit you! Go away!" The nurse concludes that this aggressive behavior is probably related to the fact that the client felt: 1. that voices were directing the behavior. 2. trapped when the nurse walked into the room. 3. afraid of doing harm to the nurse if the nurse came closer. 4. that nurse was similar to someone who was previously frightening.

2 Clients acutely ill with schizophrenia frequently do not trust others; feeling trapped may be frightening, causing them to lash out.

153. A client is delusional, talking about people who are plotting to do harm. A nurse identifies that the client is pacing more than usual and is concerned that the client is beginning to lose control. What is the best nursing intervention? 1. Advise the client to use a punching bag. 2. Move the client to a quiet place on the unit. 3. Encourage the client to sit down for a while. 4. Allow the client to continue pacing with supervision.

2 Clients losing control feel frightened and threatened. They need external controls and a reduction in external stimuli.

129. What should a nurse include in the plan of care for a client with vascular dementia? 1. A reeducation program 2. Details for supportive care 3. An introduction of new leisure-time activities 4. Plans for involvement in group therapy sessions

2 Damaged brain cells do not regenerate. Care is therefore directed toward preventing further damage and providing protection and support.

155. While a nurse is talking with a client, another client comes up and yells, "I hate you! You're talking about me again," and throws a glass of juice at the nurse. What is the nurse's best response to this outburst? 1. Repeat the client's words and ask for clarification. 2. Remove the client from the room because limits must be placed on the behavior. 3. Ignore both the behavior and the client, clean up the juice, and talk with the client later. 4. Verbalize feelings of annoyance as an example to the client that it is more acceptable to verbalize feelings than to act them out.

2 The client's behavior is escalating and unsafe. The client should be removed from the room and taken to a place where there is decreased environmental stimulation and less chance for the client to act out against others

135. When answering questions from the family of a client with Alzheimer disease, the nurse explains, "This disease is: 1. one that emerges in the fourth decade of life." 2. a slow and relentless deterioration of the mind." 3. functional in origin that occurs in the later years." 4. diagnosed through laboratory and psychologic tests."

2 This is a true statement; clients become progressively worse over time.

157. A client who experiences auditory hallucinations agrees to discuss alternative coping strategies with a nurse. For the next 3 days when the nurse attempts to focus on alternative strategies, the client gets up and leaves the interaction. What is the nurse's most therapeutic response? 1. "Come back; you agreed that you would discuss other ways to cope." 2. "You seem very uncomfortable every time I bring up a new way to cope." 3. "Did you agree to talk about other ways to cope because you thought that was what I wanted?" 4. "You walk out each time I start to discuss the hallucinations; does that mean you've changed your mind?"

2 This response focuses on a feeling that the client may be experiencing and provides an opportunity to validate the nurse's statement.

166. A regressed, emotionally disturbed client who has been watching a nurse for a few days suddenly walks up and shouts, "You think you're so damned perfect and good. I think you stink!" What is the nurse's most appropriate response? 1. "Do you mean I smell?" 2. "You seem angry with me." 3. "Boy, you're in a bad mood." 4. "I can't be all that bad, can I?"

2 This response reflects on the client's feelings rather than focusing on the verbalization.

142. An older adult is brought to the clinic by a family member because of increasing confusion over the past week. What can the nurse ask clients to assess their orientation to place? 1. Explain a proverb. 2. State where they were born. 3. Identify the name of the town. 4. Recall what they had eaten for breakfast

3 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.

133. An older adult on the mental health unit begins acting out while in the day room. What is a nurse's initial intervention? 1. Instruct the client to be quiet. 2. Allow the client to act out until fatigue sets in. 3. Give the client directions in a firm, low-pitched voice. 4. Guide the client from the room by gently holding the client's arm.

3 Clients who are out of control are seeking control and frequently respond to simple directions stated in a firm voice.

167. A client tells the nurse, "I am a terrible, evil person; the voices are telling me that God needs to punish me." What is the nurse's most therapeutic initial response? 1. "God is loving and will not punish you." 2. "Those voices you are hearing are a fantasy." 3. "Tell me what you are thinking about yourself." 4. "You aren't wicked, since both God and I love you."

3 Encouraging the client to focus on the self will facilitate communication and foster self-perception

165. How should a nurse intervene when a regressed, emotionally disturbed client voids on the floor in the sitting room of the mental health unit? 1. Make the client mop the floor. 2. Restrict the client's fluids for the rest of the day. 3. Toilet the client more frequently with supervision. 4. Withhold the client's privileges each time the client voids on the floor.

3 The client is voiding on the floor not to express hostility but because of confusion. Taking the client to the toilet frequently limits voiding in inappropriate places.

128. When attempting to assess the behavior of an older adult diagnosed with vascular dementia, a nurse considers that the client probably is: 1. not capable of using any defense mechanisms. 2. using one method of defense for every situation. 3. making exaggerated use of old, familiar mechanisms. 4. attempting to develop new defense mechanisms to meet the current situation.

3 These clients attempt to use defense mechanisms that have worked in the past but use them in an exaggerated manner. Because of brain cell destruction, they are unable to develop new defense mechanisms.

158. What is a nurse's most appropriate action when a client is seen openly masturbating in the recreation room? 1. Restraining the client's hands 2. Putting the client in seclusion 3. Escorting the client out of the room 4. Teaching the client acceptable behavior

3 This accepts the client but rejects the behavior. The nurse should set limits on this behavior when it is not performed in a private area

152. During the admission procedure, a client appears to be responding to voices. The client cries out at intervals, "No, no, I didn't kill him. You know the truth; tell that police officer. Please help me!" What is the nurse's most appropriate response? 1. Sit quietly and not respond to the client's statements. 2. Listen attentively and assume a facial expression of disbelief. 3. Respond by saying, "I want to help you. I realize you must be very frightened." 4. Say, "Do not become so upset. No one is talking to you; those voices are part of your illness."

3 This response demonstrates an understanding of the client's feelings and encourages the client to share feelings, which is an immediate need.

124. A nurse is conducting a mini-mental status examination on an older client. What should the nurse ask the client to do when testing shortterm memory? 1. Subtract serial 7s from 100. 2. Copy one simple geometric figure. 3. State three random words mentioned earlier in the exam. 4. Name two common objects when the nurse points to them.

3 This technique tests the client's ability to recall from short-term memory.

What clinical manifestation is the most serious indication of impending assaultive behavior by a client on a mental health unit? 1. Uses profane language 2. Touches people excessively 3. Exhibits a sudden withdrawal 4. Experiences command hallucinations

4 Command hallucinations are dangerous because they may influence the client to engage in behavior dangerous to self or others.

146. What should a nurse do when caring for a client whose behavior is characterized by pathologic suspicion? 1. Protect the client from environmental stress. 2. Help the client realize the suspicions are unrealistic. 3. Ask the client to explain the reasons for the feelings. 4. Help the client to feel accepted by the staff on the unit

4 Delusions are protective and can be abandoned only when the individual feels secure and adequate. This response is the only one directed at building the client's security and reducing anxiety.

143. A nurse is assigned to care for a regressed college student who has been talking to unseen people and refusing to get out of bed, go to class, or get involved in daily grooming activities. What is the nurse's initial effort toward helping this client? 1. Providing frequent rest periods 2. Reducing environmental stimuli 3. Facilitating the client's social relationships with a peer group 4. Attempting to establish a meaningful relationship with the client

4 The first step in a plan of care should be the establishment of a meaningful relationship because it is through this relationship that the client can be helped.

139. What is the priority nursing objective of the therapeutic psychiatric environment for a confused client? 1. Assist the client to relate to others. 2. Make the hospital atmosphere more home-like. 3. Help the client become accepted in a controlled setting. 4. Maintain the highest level of safe, independent functioning.

4 The therapeutic milieu is directed toward helping the client develop effective ways of functioning safely and independently

149. A client with schizophrenia is admitted to an acute care psychiatric unit. Which clinical findings indicate positive signs and symptoms associated with schizophrenia? 1. Withdrawal, poverty of speech, inattentiveness 2. Flat affect, decreased spontaneity, asocial behavior 3. Hypomania, labile mood swings, episodes of euphoria 4. Hyperactivity, auditory hallucinations, loose associations

4 These are positive symptoms associated with schizophrenia; positive symptoms reflect a distortion or excess of normal functions.

161. A nurse enters a client's room and identifies that the client appears preoccupied. Turning to the nurse, the client states, "They are saying terrible things about me. Can't you hear them?" What is the nurse's most therapeutic response? 1. "It seems you heard them before." 2. "Try to get control of your feelings." 3. "There is no one here but me, and I don't hear anything." 4. "I don't hear anyone else talking, but I can see you are upset."

4 This response interjects reality and focuses on the client's behavior.

125. A nurse is teaching a client and family about the characteristics of dementia of the Alzheimer type. What characteristic should the nurse include? 1. Periodic exacerbations 2. Aggressive acting-out behavior 3. Hypoxia of selected areas of brain tissue 4. Areas of brain destruction called senile plaques

4 When an older person's brain atrophies, some unusual deposits of iron are scattered on nerve cells. Throughout the brain, areas of deeply staining amyloid, called senile plaques, can be found; these plaques are end stages in the destruction of brain tissue.

136. A client in the early dementia stage of Alzheimer's disease is admitted to a long-term care facility. Which activities must the nurse initiate? Select all that apply. 1. Weigh the client once a week. 2. Have specialized rehabilitation equipment available. 3. Keep the client in pajamas and robe most of the day. 4. Establish a schedule with periods of rest after activities. 5. Review the client's weekly budget and use of community resources. 6. Set up a plan for weekly entertainment through a senior citizens group.

Answer: 1, 2, 4

134. A nurse is assessing an older adult with the diagnosis of dementia. Which manifestations are expected in this client? Select all that apply. 1. Resistance to change 2. Inability to recognize familiar objects 3. Preoccupation with personal appearance 4. Inability to concentrate on new activities or interests 5. Tendency to dwell on the past and ignore the present

Answer: 1, 2, 4, 5.

138. A nurse is assessing a client with dementia. Which clinical manifestations are expected? Select all that apply. 1. Agitation 2. Pessimism 3. Short attention span 4. Disordered reasoning 5. Impaired motor activities

Answer: 1, 3, 4, 5.

130. A nurse is assessing a client and attempting to distinguish between dementia and delirium. Which factors are unique to delirium? Select all that apply. 1. Slurred speech 2. Lability of mood 3. Long-term memory loss 4. Visual or tactile hallucinations 5. Insidious deterioration in cognition 6. Fluctuating levels of consciousness

Answer: 1, 4, 6.

144. A client diagnosed with schizophrenia is experiencing auditory hallucinations. A nurse makes the following statements when interacting with this client. Place these statements in the order in which they should occur. 1. _____ "I do not hear any voices." 2. _____ "Come with me for a walk." 3. _____ "Hearing voices must be frightening."] 4. _____ "The voices you hear are part of your illness." 5. _____ "Let's play cards with another client in the recreation room."

Answer: 3, 4, 1, 2, 5.

141. What are the four "As" for which nurses should assess clients suspected of having Alzheimer disease? 1. Amnesia, apraxia, agnosia, aphasia 2. Avoidance, aloofness, asocial, asexual 3. Autism, loose association, apathy, affect 4. Aggressive, amoral, ambivalent, attractive

1 Neurofibrillary tangles in the hippocampus cause recent memory loss (amnesia); temporoparietal deterioration causes cognitive deficiencies in speech (aphasia), purposeful movements (apraxia), and comprehension of visual, auditory, and other sensations (agnosia).

159. What should the nurse do to achieve a primary objective of providing a therapeutic daycare environment for a client who is withdrawn and reclusive? 1. Foster a trusting relationship. 2. Administer medications on time. 3. Involve the client in a group with peers. 4. Remove the client from the family home.

1 An interpersonal relationship based on trust must be established before clients can be helped

168. What is the most appropriate way for the nurse to help a withdrawn, emotionally disturbed adolescent client to accept the realities of daily living? 1. Assist the client to care for personal hygiene needs. 2. Encourage the client to keep up with school studies. 3. Persuade the client to join the other clients in group activities. 4. Leave the client alone when there appears to be a disinterest in daily activities.

1 Assisting clients with grooming keeps them in contact with reality and allows them to realize that staff members care enough to help.

145. A client with schizophrenia has a history of hearing voices that say, "You are a bad person." While having a conversation with a nurse with whom the client has been working, the client states, "I am starting to hear the same voices again." What is the nurse's best response? 1. "Try to ignore the voices." 2. "What are the voices saying to you?" 3. "Do you believe what the voices are saying?" 4. "Try not to be afraid because they are only voices."

1 Clients can sometimes learn to push auditory hallucinations aside, particularly within the framework of a trusting relationship; it may provide the client with a sense of power to manage the voices

148. A delusional client refuses to eat because of a belief that the food is poisoned. What is the most appropriate initial nursing intervention? 1. State that the food is not poisoned. 2. Taste the food in the client's presence. 3. Show the client that other people are eating without being harmed. 4. Tell the client that tube feedings will be started if eating does not begin.

1 Clients cannot be argued out of delusions, so the best approach is a simple statement of reality.

131. A delirious client sees a design on the wallpaper and perceives it as an animal. How should a nurse communicate what the client perceived at the change of shift report? 1. A delusion 2. An illusion 3. A hallucination 4. An idea of reference

2 An illusion is a misperception or misinterpretation of an actual external stimulus.

132. A nurse's best approach when caring for a confused, older client is to provide an environment with: 1. space for privacy. 2. group involvement. 3. trusting relationships. 4. activities that are varied.

3 A one-to-one trusting relationship is essential to help the client become more involved and interested in interpersonal relationships.

137. Nurses working with clients who have a diagnosis of dementia should adopt a common approach of care because these clients need to: 1. relate in a consistent manner to staff. 2. learn that the staff cannot be manipulated. 3. accept controls that are concrete and fairly applied. 4. have sameness and consistency in their environment

4 A consistent approach and consistent communication from all members of the health team help the client who has dementia remain more reality-oriented.

127. Which nursing intervention is most helpful in meeting the needs of an older adult with the diagnosis of dementia of the Alzheimer type? 1. Providing nutritious foods high in carbohydrates and proteins 2. Offering opportunities for choices in the daily schedule to stimulate interest 3. Developing a consistent plan with fixed time schedules to provide for emotional needs 4. Simplifying the environment as much as possible and eliminating the need for decisions and choices

4 Clients with this disorder need a simple environment. Because of brain cell destruction, they are unable to make choices.