Nursing Concept: Cognition 450

A client who experienced an ST elevation myocardial infarction (STEMI) received fibrinolytic therapy with streptokinase. Which manifestation alerts the nurse to a developing complication?

Decreased level of consciousness

An older adult client may be experiencing symptoms of tertiary syphilis. Which characteristic would the nurse associate with tertiary syphilis years after the initial infection?

Dementia Tertiary syphilis is a delayed response of the untreated disease. The symptomatic tertiary stage frequently affects the cardiovascular system, central nervous system, and the liver, bones, and testes. Central nervous system lesions can produce dementia, blindness, or injury to the spinal cord, with ataxia and sensory loss. Chancre is the primary syphilitic lesion. Second-stage syphilis is characterized by a maculopapular rash of the palms of the hands or soles of the feet. Condylomata lata are genital lesions that are highly infectious.

The nurse is caring for a 12-year-old with cerebral palsy who is unable to communicate verbally. Which pain assessment tool is the most appropriate for the nurse to use when assessing pain in this client?

Face, leg, activity, cry, and consolability (FLACC) descriptors

When explaining dissociative disorders to a client, what feature of these disorders would a nurse describe?

Failure to integrate identity, memory, and consciousness Explanation: The essential feature of these disorders involves a failure to integrate identity, memory, and consciousness. That is, unwanted intrusive thoughts disrupt one's contact with the here and now, or memories that are normally accessible are lost. These disorders are closely related to trauma- and stressor-related disorders but are categorized separately.

The nurse is conducting an admission assessment with a 45-year-old client who has been demonstrating signs of bipolar disorder. While conducting the assessment, the client starts speaking in illogical rhymes and using word associations. What is the name for this thought pattern?

Flight of ideas Explanation: Rapid "flights of ideas" lead to excessive and illogical rhyming, punning, and word associations, along with pressured speech.

A patient sustained a head injury during a fall and has changes in personality and affect. What part of the brain does the nurse recognize has been affected in this injury?

Frontal lobe Explanation: The frontal lobe, the largest lobe, located in the front of the brain. The major functions of this lobe are concentration, abstract thought, information storage or memory, and motor function. It contains Broca's area, which is located in the left hemisphere and is critical for motor control of speech. The frontal lobe is also responsible in large part for a person's affect, judgment, personality, and inhibitions

The nurse is assigned to care for a client with early stage Alzheimer's disease. Which nursing interventions should be included in the client's care plan? Select all that apply

Furnish the client's environment with familiar possessions. Assist the client with activities of daily living (ADLs) as necessary. Assign tasks in simple steps.

A client with schizophrenia is receiving antipsychotic therapy. The nurse understands that which is a medical emergency should it develop in the client?

Neuroleptic malignant syndrome Although tardive dyskinesia, parkinsonism, and akathisia can occur with antipsychotic therapy, neuroleptic malignant syndrome is a life-threatening condition and medical emergency that requires immediate treatment.

A nurse must assess a client's thought process and content to identify risk for aggression. The assessment of the client's thought process and content would allow the nurse to identify what?

Perceptions and delusions The thought processes and content of greatest interest to the nurse in assessing a client's potential for aggression and violence are perception and delusion.

A client has been prescribed clozapine for schizoaffective disorder (SCA) with depression. The nurse should explain to the client that one advantage of clozapine is that it can provide what?

Reduction of hospitalizations and risk for suicide

A nurse suggests that the client explores new ideas about a particular problem and considers other possibilities to reflect:

A cognitive intervention. Explanation: Cognitive interventions are usually those that provide new ideas, opinions, information, or education about a particular problem. The nurse offers a cognitive intervention with the goal of inviting the client to consider other possibilities.

A nurse is caring for a client with dissociative disorder. The nurse tells the client, "Hello, I'm Robin, your nurse. It is 9 o'clock in the morning now. You are in room number 303. My name is Robin, I'm your nurse." What is the most appropriate reason for the nurse to repeat this statement?

The client may need to be reoriented.

During a mental status exam, what conclusion should the nurse draw when the client is able to complete fewer than half of tasks accurately?

The client's cognitive deficit is significant

The nurse is talking with the parents of a child who has been identified as having a learning disability. The parents state that their child performs well on oral examinations but otherwise struggles on exams. The nurse is aware that the parents are describing which disorder?

dyslexia

Parents are reluctant to accept that their preschooler has attention deficit hyperactivity disorder (ADHD), so the nurse is explaining the commonly seen characteristics of this syndrome. Which characteristics would the nurse include in the explanation? Select all that apply.

easily distracted failure to complete tasks before going on to another one impulsivness Children with ADHD or ADD (attention deficit disorder) usually demonstrate an inability to stay on task, are impulsive, lose things frequently, are fidgety and cannot sit still, and tend to talk all the time. Aggression and bedwetting are not part of this syndrome.

A group of friends have arrived at the hospital to visit a client recently diagnosed with delirium. The nurse tells the friends they can visit with the client one at a time. What is the likely reason for the nurse to give this instruction?

The nurse wants to prevent increasing the client's confusion.

A client with dissociative disorder is referred for psychotherapy. What would be the main focus of therapy for this client?

To reassociate with conciousness The main focus of therapy in dissociative clients is to reassociate and put consciousness back together. Having a positive outlook toward life is a long-term goal for these clients and is not the main focus of therapy. Combating feelings such as guilt and self-blame and helping the client face troublesome thoughts are the goals of treatment for clients with posttraumatic stress disorder.

A client is admitted to the psychiatric hospital with a diagnosis of schizophrenia. During the physical examination, the client's arm remains outstretched after the nurse obtains the pulse and blood pressure, and the nurse must reposition the arm. The nurse interprets this as what?

Waxy flexibility Explanation: Waxy flexibility, the ability to assume and maintain awkward or uncomfortable positions for long periods, is characteristic of catatonic schizophrenia. Clients commonly remain in these awkward positions until someone repositions them. Exchopraxia refers to the involuntary imitation of another person's movements and gestures. Hypervigilance refers to the sustained attention to external stimuli, as if expecting something important or frightening to occur. Retardation refers to slowed movements.

Which form of progressive dementia is often a result of chronic alcoholism?

Wernicke-Korsakoff syndrome

The English-speaking nurse is assessing a 12-month-old child with an English-speaking father and a Spanish-speaking mother. The child does not use words like "drink" "dog" or "ball." What is the nurse's priority intervention?

asking the mother if the child uses Spanish words for those items

The spouse of a client admitted to the hospital after a motor vehicle accident reports to the nurse that the client has become very drowsy. The nurse should:

assess the client for additional signs/symptoms of increased intracranial pressure.

A young parent brings the school-aged child to the office for a sports physical examination. During the appointment, the parent informs the nurse about being worried because the child does not like school and does not seem to be reading, writing, or spelling as well as others in the class. The parent adds that the child struggles to get organized and to manage time. What condition does the nurse suspect?

learning disorder The child appears to have a learning disorder based on challenges with reading, spelling, and writing as well as being organized and managing time. Other findings consistent with a learning disorder include delayed language development and difficulty discriminating among sounds. Autism spectrum disorder represents a range of disorders characterized by markedly abnormal or impaired development in social interaction and communication. Down syndrome is a condition in which extra genetic material causes delays in how a child develops, both physically and cognitively. Asperger syndrome is a type of autism spectrum disorder.

A client has been receiving chlorpromazine as treatment for psychosis. Which assessment finding indicates to the nurse that the client is experiencing an extrapyramidal effect of the medication?

motor restlessness Explanation: Chlorpromazine has severe adverse effects that impact the central nervous system, the cardiac system, and the hematologic system. Extrapyramidal effects may also occur including motor restlessness, or akathisia. Fatigue, dizziness, and slurred speech are central nervous system effects from the medication.

The nurse is assessing a client with schizophrenia who was prescribed clozapine several months ago. Which metabolic effect indicates to the nurse that the client has stopped taking the medication?

recent weight loss of 5 lb (2.3 kg) Clozapine has several adverse effects. Metabolic effects include weight gain. If the client were taking the medication as prescribed, a weight loss of 5 lb (2.3 kg) would not have occurred. Rapid heart rate, hyperglycemia, and severe constipation are all adverse effects associated with taking the medication.

Following focal seizures that have damaged the dominant hemisphere of a client's auditory association cortex, the nurse may observe the client displaying:

receptive aphasia Damage to the auditory association cortex, especially if bilateral, results in deficiencies of sound recognition and memory (auditory agnosia). If the damage is in the dominant hemisphere, speech recognition can be affected (sensory or receptive aphasia). The others are not caused by focal seizures.

To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should

stay with the client and encourage them to eat

Which lobe of the brain houses the cerebral cortical structure responsible for language comprehension?

temporal The Wernicke area of the temporal lobe is responsible for language comprehension, while the occipital lobe is responsible for receiving visual information from the eyes. The hippocampus is important for explicit memory, reality testing, and inhibition of the amygdala. The parietal lobe is essential in the integration and processing of sensory information.

When examining a client who has abdominal pain, a nurse should assess

the symptomatic quadrant last.

The client has finished the first round of chemotherapy. Which statement made by the client indicates a need for further teaching by the nurse?

"I can continue taking my vitamins and herbs because they make me feel better."

A client is being prepared for a cochlear implant. Which client statement would alert the nurse to the need for additional teaching?

"I'm going to be able to hear normally again."

Cognitive interventions are based on the concept of cognition. Who developed cognitive behavioral therapy?

Aaron Beck

A mental health nurse is caring for a client with schizophrenia. The nurse observes the client laughing about the recent death of the client's father, then cries when the family delivers the news. What will the nurse explain to the family regarding this behavior?

"A labile mood is seen with this type of reaction." Explanation: The correct answer is labile mood, which is changeable, as seen in the behavior of the client. In this instance, laughing one minute and crying the next. Labile affect is the abnormal fluctuation of one's expressions. This behavior is not displaying the intensity of the mood. Intensity can be increased, flat, or blunted. The nurse determines whether the emotional response is appropriate for the situation. For example, an inappropriate response is shown by a client who has an extreme reaction to the death of the victims of a mass tragedy, as if the victims were personal friends. In this case the behavior of the client may not be appropriate to the family, but this behavior is a labile affect of abnormal fluctuations. The client is not displaying elements of euphoria. Euphoric mood is one of elation.

A nurse is monitoring a patient with Alzheimer's disease for initiation of therapy. In which patient is the administration of donepezil contraindicated?

A patient with asthma Explanation: The administration of cholinesterase inhibitors is contraindicated in patients with asthma. Use is not contraindicated in patients with bronchitis, beriberi, or amnesia.

A client with schizophrenia reads the advice column in the newspaper daily. The client states, "This person is my guide and tells me what I must do every day." Which is the best response by the nurse?

"Can you tell me why you are so interested in the advice column?" Explanation: Referential delusions or ideas of reference involve the client's belief that television broadcasts, music, or newspaper articles have special meaning for them. The nurse can ask the client why they are interested to clarify the meaning of the statement. Attempting to ridicule or demean the client by inferring that they are not famous for the author to give advice or that they are not talking to them is a nontherapeutic response. Arguing with the client about taking their own advice is nontherapeutic and a caustic response.

A client with a diagnosis of schizophrenia is admitted to the inpatient unit of the mental health center. The client starts shouting, "The government of France is trying to kill me!" Which response is most appropriate?

"I don't see evidence that a foreign government is trying to hurt you. You must feel frightened by this." Responses should focus on reality while acknowledging the client's feelings. It isn't therapeutic for the nurse to argue with the client or deny the client's belief. Arguing can also inhibit the development of a trusting relationship. Continuing to talk about delusions may aggravate the client's psychosis. A therapeutic response should focus on the client, not the nurse or previous clients. Asking the client to explore the delusion may increase the client's anxiety level and can reinforce the delusions.

The nurse is talking with the parent of a 4-year-old that has been toileting independently for 2 years and with the birth of a sibling has started wetting their pants again. Which response to the parent will be most therapeutic?

"It is likely the child has regressed to a previous developmental stage when needs were met."

The nurse is teaching a client with schizoaffective disorders (SAD) about the client's prescribed medication therapy. The nurse determines that additional education is needed when the client states what?

"One day, I won't have to worry about taking any medication." Explanation: After the client's condition has stabilized (i.e., the client exhibits a decrease in positive and negative symptoms), the treatment that led to remission of symptoms should be continued. Titrating antipsychotic agents to the lowest dose that provides suitable protection may enable optimal psychosocial functioning while slowing the recurrence of new episodes. Clients diagnosed with SAD are unlikely to be medication free. Clients also need education about preventing orthostatic hypotension, such as changing positions slowly, as well as drinking adequate amounts of fluid each day. Clients also need to notify their health care provider if they notice any abnormal muscle movement or the inability to control motor movement.

The adult child of a client with end-stage Alzheimer disease asks the nurse if Alzheimer disease can be passed on to him or her. What is the nurse's most accurate response?

"Research supports a possible genetic link with an early onset."

A client is admitted to the psychiatric unit with delusional thinking. The client, who is overweight and has a history of eating when stressed, now shows a lack of interest in eating at meal times. The client states, "I am unworthy of eating. My children will die if I eat." Which response by the nurse is most appropriate?

"That sounds scary. Tell me more about how you are feeling."

A 5-year-old child fell on the playground and briefly lost consciousness. Magnetic resonance imaging (MRI) of the head was normal, and the child is now alert and awake with stable vital signs. The nurse provides discharge teaching for this family. Which statement by the caregiver indicates a need for additional teaching by the nurse?

"We will wake the child up every hour to assess overnight."

The nurse is preparing to assess a client's remote memory. Which questions would be mostappropriate for the nurse to ask?

"When did you get your first job?" Asking the client about when he or she got his or her first job gives information about the client's remote memory or past events. Asking about what the client ate in the past 24 hours or what he or she did last evening provides information about the client's recent memory. Asking how an apple and orange are similar tests abstract reasoning.

Which client statement is suggestive of a sexual delusion?

"You've been watching me and my partner while we are together, haven't you? Explanation: Sexual delusions involve a client's belief that his or her sexual behavior is known to others; that the client is a rapist, prostitute, or pedophile; or that the client is pregnant. Questioning that the client and the client's partner are being watched is consistent with the definition for sexual delusions.

What are the most common mental health problems in the United States? Select all that apply.

Depression Anxiety Substance abuse

After assessing a client with schizophrenia, the nurse notes that the client exhibits signs and symptoms related to being unable to experience pleasure. The nurse documents this finding as what?

Anhedonia Explanation: Anhedonia refers to the inability to experience pleasure. Diminished emotional expression is reflected by a restriction or flattening in the range and intensity of emotion. Alogia refers to a reduced fluency and productivity of thought and speech. Avolition refers to withdrawal and inability to initiate and persist in goal-directed activity.

A nurse is caring for a client with advanced dementia and depression who states, "I don't want to live with my family, because they are mean and they think I have lost my mind." The nurse observes that the family members are attentive and supportive when they visit. What will be the nurse's initial action?

Ask the family about how the client was functioning at home when they next visit. Explanation: A client with advanced dementia may not be oriented to reality and may misinterpret the actions of others. Therefore, the nurse should talk with the family about how the client is functioning at home. Asking the client to describe how their family has been mean is not appropriate, because the client may not provide factual information. The nurse may feel the need to discuss the case with the social worker after talking with the client's family, but talking with the family should be the nurse's initial action. The nurse may document the client's statements and plan of action, but it isn't necessary for the nurse to notify the healthcare provider at this time.

A client has vascular neurocognitive disorder. When teaching the family about the cause of this disorder, which would the nurse expect to integrate into the explanation?

Blood flow in the vessels to the brain are blocked. Explanation: Vascular neurocognitive disorder, also called multi-infarct dementia, is caused by conditions that block or reduce blood flow to the brain. Tangles are found in clients with Alzheimer's disease, when proteins intended to provide stability in neurons are tangled together. Decreased acetylcholine production is thought to be a cause of Alzheimer's disease, with less of the enzyme needed to produce acetylcholine found in the brains of affected clients. Plaques are also found in the brains of clients with Alzheimer's disease. Proteins mix together to form plaques. The more plaques present, the more signs of degeneration are also found in affected clients.

The nurse is working with a client seeking treatment for bulimia and determines that cognitive restructuring will help build the client's self-esteem. Which best describes the goals of cognitive restructuring?

Change distorted thinking and the subsequent behaviors Explanation: The goals of cognitive restructuring are for clients to monitor their maladaptive thoughts and beliefs, look for evidence supporting their beliefs, dispute their maladaptive self-statements, substitute adaptive thoughts, and thus change their patterns of distorted thinking and, consequently, their behavior. Avoiding negative self talk is not a goal of cognitive restructuring; the aim is to identify it so the client can change it. Finding a sounding board for identifying and discussing feelings is one of the goals of crisis intervention. Using adaptive defense mechanisms is not part of cognitive restructuring; rather it is a component of behavioral therapy.

The nurse is assessing a client with psychiatric disorder. The nurse finds that when asked a question, the client gives excessive and unnecessary details followed by the answer. This is indicative of which impairment of thought content?

Circumstantial thinking When a client gives excessive and unnecessary details and then gives the answer, this is termed circumstantial thinking. Flight of ideas is characterized by an excessive amount and rate of speech composed of fragmented or unrelated ideas. Loose association is characterized by jumping from one idea to another with little or no evident relation between the thoughts. Thought broadcasting is when the client has the delusional belief that others can hear or know what the client is thinking.

A nurse is caring for an older adult who has experienced damage to the frontal lobe after an automobile accident. The nurse anticipates that the client will have difficulty with which function?

Concept formation Working memory is an important aspect of frontal lobe function. The nurse can anticipate that the client will have difficulty with concept formation, insight, judgment, and reasoning. The temporal lobes contain the primary auditory and olfactory areas. Wernicke's area, located at the posterior aspect of the superior temporal gyrus, is primarily responsible for receptive speech.

The nurse is working with a client who is in a stressful situation. The nurse evaluates the client's resiliency by assessing the client's ability to do what?

Continue to function well Explanation: Resilience has been defined by researchers as the ability of a person to function well in stressful situations. It is demonstrated by controlling strong emotional reactions, using appropriate communication and problem-solving skills, and knowing when to take action, when to rely on others, and when to nurture the self.

A nurse is assessing a 20-year-old adult who has come to the clinic for a checkup. Which finding would the nurse expect when assessing this client's cognitive development?

Creative thought Objectivity Realistic view of the world

A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes?

Decreased acetylcholine level A decreased acetylcholine level has been implicated as a cause of cognitive changes in healthy elderly clients and in the severity of dementia. Choline acetyltransferase, an enzyme necessary for acetylcholine synthesis, has been found to be deficient in clients with dementia. Norepinephrine is associated with aggression, sleep-wake patterns, and the regulation of physical responses to emotional stimuli, such as the increased heart and respiratory rates caused by panic.

An older adult client enjoys good overall health, but has just been diagnosed with pneumonia and has begun receiving an intravenous (IV) antibiotic. Shortly after being administered the first dose, the client pulled out his IV line and is now attempting to scale his bed rails. Which of the following phenomena most likely underlies this change in the client's cognition?

Delirium Delirium is a temporary state of confusion that is often precipitated by drug interactions or the effects of new drugs. Dementia is rooted in organic brain changes and rarely has a sudden onset. The client is not showing signs or symptoms of depression. Disorientation is a manifestation of a problem rather than a cause.

The nurse is developing a care plan for a client with somatic delusions. Which would be an appropriate nursing diagnosis for this client?

Disturbed thought process The most appropriate nursing diagnosis for this client is disturbed thought process related to misperception of environmental stimuli. Disturbed sleep pattern, risk for self-directed violence, and chronic low self-esteem would not be the most appropriate nursing diagnosis for this client.

A client has a diagnosis of Parkinson disease, a health problem that has effects on motor function and cognition. What neurotransmitter is most likely deficient in this client's CNS?

Dopamine Explanation: Dopamine levels are disrupted in Parkinson disease, as evidenced by the profound effects of motor function and cognition. Norepinephrine, acetylcholine and GABA do not have this combination of motor and cognitive functions.

The nurse is providing education to a client who has been prescribed hydroxyzine. What adverse effect should the nurse mention during teaching?

Drowsiness

The nurse is caring for a client who is receiving cyclobenzaprine for relief of muscle spasms. What adverse effect should the nurse assess for?

Drowsiness A common adverse effect with cyclobenzaprine is drowsiness. The client will not experience muscle spasms, insomnia, or urinary incontinence as a result of this medication therapy.

A client has been prescribed quetiapine for delusional disorder. In teaching the client about this medication, the nurse must be certain to include which information?

One of the common side effects is dry mouth.

A nurse is preparing to administer prescribed antipsychotic medication to a client with psychosis. The nurse identifies the prescribed medication as a first-generation antipsychotic drug. Which drug would the nurse most likely be administering?

Fluphenazine

The nurse is caring for a 12-month-old with autism spectrum disorder (ASD). What description would you expect to elicit from his mother on history-taking?

He stares at a rotating wheel on his crib mobile. Children with ASD seem fascinated by whirling or spinning toys or objects. They are nonverbal and have difficulty forming close relationships.

A nurse is caring for a client with delirium. The client sees a thermometer on the nurse's table and shouts, "Don't stab me!" and cowers. Which feature of delirium is this client exhibiting?

Illusion Clients with delirium may experience illusions. In this case, the client is having an illusion that the thermometer is a knife. Euphoria refers to an extremely elated mood; however, the client does not appear to be highly elated. Hallucinations are typically things that clients "see" with no stimulus in reality. Misinterpretations are a misunderstanding of an actual event or stimulus. In many cases, the client cannot be convinced that their misinterpretation is incorrect.

A client is brought to the emergency department after injuring their right arm in a bicycle accident. The orthopedic surgeon tells the nurse that the client has a greenstick fracture of the arm. What does this mean?

One side of the bone is broken and the other side is bent.

Rebleeding may occur from a peptic ulcer and often warrants surgical interventions. Signs of bleeding include which of the following?

Mental confusion

The nurse is caring for a client with asterixis. Which assessment should the nurse make to help a diagnosis of hepatic encephalopathy?

Mental status Hepatic encephalopathy refers to the totality of central nervous system manifestations of liver failure. It is characterized by neural disturbances ranging from a lack of mental alertness to confusion, coma, and convulsions. A very early sign of hepatic encephalopathy is a flapping tremor called asterixis.

A young adult client comes to the clinic reporting that he is extremely sleepy during the day with memory lapses, even when going to bed early, waking up several times during the night, and brief periods of muscle weakness. Which syndrome do these manifestations indicate?

Narcolepsy Narcolepsy is a syndrome characterized by abnormal sleep tendencies, including excessive daytime sleepiness, disturbed nocturnal sleep, and manifestations related to rapid eye movement sleep such as cataplexy, hypnagogic hallucinations, and sleep paralysis. Daytime sleepiness is the most common initial symptom of narcolepsy. It is most apparent in boring, sedentary situations and often is relieved by movement. Sleep apnea may cause daytime sleepiness but not the other characteristics of narcolepsy. Restless legs syndrome and periodic limb movement disorder do not have the same characteristics of narcolepsy.

A client receives the first dose of fluphenazine. The next day, during the follow-up appointment, the nurse finds the client is confused and mute, and the client's temperature is 103°F. The client also presents with rigidity and diaphoresis. The nurse should investigate further for which condition?

Neuroleptic malignant syndrome The most serious and potentially fatal side effect of the typical antipsychotics is neuroleptic malignant syndrome, characterized by severe muscular rigidity, altered consciousness, disorientation, dysphagia, elevated creatinine phosphokinase, stupor, catatonia, hyperpyrexia, and labile pulse and blood pressure. This life-threatening condition can occur after a single dose of a neuroleptic; however, it is more common in the first 2 weeks of administration or with an increase in dose. It can continue for up to 2 weeks after discontinuation of the medication. Serotonin syndrome has some overlapping signs and symptoms, but it is characterized by hyperreflexia rather than rigidity and is usually the result of taking an MAOI and an SSRI.

While caring for a hospitalized client diagnosed with schizophrenia, a nurse observes that the client is listening to the radio. The client tells the nurse that the radio commentator is speaking directly to the client. The nurse interprets this finding as which type of thinking?

Referential The client is exhibiting referential thinking, that is, the belief that neutral stimuli, such as the radio, have special meaning to that person, such that the radio commentator is talking directly to him. Autistic thinking involves restriction of thinking to the literal and immediate so that the individual has private rules of logic and reasoning that make no sense to anyone else. Concrete thinking reflects a lack of abstraction in thinking with the inability to understand punch lines, metaphors, and analogies. Illusional thinking occurs when a person misperceives or exaggerates stimuli that actually exist in the external environment.

A client with Alzheimer's disease is admitted to an inpatient setting and has memory loss, wandering, and disorientation. What nursing intervention should be the priority to initiate in the client's care plan?

Remove potential hazards from the client's environment.

A nurse is conducting an in-service education program for a group of nurses transitioning to the pediatric unit of the facility. The nurse is describing the various theories of growth and development. The nurse determines that the teaching was successful when the group identifies the stages of cognitive development by Piaget. Place the stages listed below in the correct sequence from first to last that would demonstrate the group's learning.

Sensorimotor Pre-operational Concrete operational Formal operational Piaget identified four stages of cognitive development: sensorimotor (birth to 2 or 3 years), pre-operational (ages 2 or 3 to 6 or 7 years), concrete operational (ages 6 or 7 to 11 or 12 years); and formal operational (ages 11 or 12 to 14 or 15 years).

A client diagnosed with delusional disorder who uses excessive health care resources most likely has which type of delusions?

Somatic Explanation: Persons who have somatic delusions believe they have a physical ailment. Clients with somatic delusions use excessive health care resources. The central theme of the jealous subtype is the unfaithfulness or infidelity of a spouse or lover. Nihilistic delusions focus on death or calamity. Clients presenting with grandiose delusions are convinced they have a great, unrecognized talent or have made an important discovery; a less common presentation is the delusion of a special relationship with a prominent person or actually being a prominent person.

While interviewing a client diagnosed with a delusional disorder, the client states, "I have this really strange odor coming out of my mouth. I stop to brush my teeth almost every hour and then rinse with mouthwash every half hour to get rid of this smell. I've seen so many doctors, and they can't tell me what's wrong." The nurse interprets the client's statement as reflecting which type of delusion?

Somatic The client's statements reflect a somatic delusion, which involves bodily functions or sensations. Those with somatic delusions use excessive health care resources and often go through elaborate rituals to cleanse themselves or their surroundings. Erotomanic delusions focus on the belief that the client is loved intensely by a "loved object," who is usually married, of a higher economic status, or otherwise unattainable. With grandiose delusions, the client is convinced that they have a great, unrecognized talent or has made an important discovery. Jealous delusions focus on the unfaithfulness or infidelity of a spouse or lover.

Which assessment findings in a client who is suspected of having a delusional disorder would be suggestive of a diagnosis of schizophrenia?

The client experiences frequent and sustained hallucinations. Explanation: The presence of prominent and sustained hallucinations is suggestive of schizophrenia rather than delusional disorder. Nonbizarre delusions are associated with delusional disorder, and people with either diagnosis lack insight. Response to therapy does not differentiate between the two diagnoses.

While doing the routine basic physical assessment of a client with posttraumatic stress disorder (PTSD), the nurse finds that the client appears totally numb with a blank stare. What does this sign most likely indicate?

The client may have dissociative symptoms. Explanation: Clients with PTSD are likely to have dissociation. It is a protective defense mechanism that helps the client to protect himself or herself from recognizing the effects of the traumatic event by allowing the mind to forget or remove itself from the painful memory. Dissociation could be manifested as the client speaking in a different tone of voice or appearing numb with a blank stare. This is not a manifestation of unconsciousness. Psychotherapy is used to help the client be more expressive. Illicit drug use is not likely to cause this behavior.

The nurse is creating a plan of care for a client experiencing delirium. Which outcome assigned will be a priority for the nurse to evaluate?

The client will be safe in their environment and free from injury. Explanation: The priority outcome is that the client remains safe in their environment and not sustains injury that is related to the alteration in sensorium. Although all of the outcomes are important in the recovery of the client, the highest priority is injury.

A psychiatric-mental health nurse is teaching a class about schizophrenia. When describing delusions, which information would the nurse most likely include?

They may include elements of a situation that could occur in real life. Delusions are fixed, false beliefs that cannot be changed by conflicting evidence. They can be situations that could occur in real life and are plausible in the context of the person's ethnic and cultural background, or they may be clearly fantastical. They usually involve a misinterpretation of the client's experience.

A client experiencing a manic phase of bipolar disorder sustained cuts on the body from falling through a store window. The nurse is preparing to start an intravenous needle insertion. How should the nurse explain the procedure to the client?

Using clear and simple terms Explanation: When communicating with clients who have psychiatric or mental health disabilities, the nurses uses clear and simple communication. The nurse needs to listen to the client and wait for the client to finish speaking. The client makes independent decisions, and the nurse does not ignore the client's refusal.

For the past 2 years, a client has had increasing difficulty remembering the events of the day, but has been able to recall events from the distant past. The client's motor skills have slowed, despite the absence of arthritis. Recent echocardiography showed the presence of atherosclerosis and the client experienced a myocardial infarction earlier this year. Which neurologic condition does the client most likely have?

Vascular dementia Vascular dementia is caused by brain injury resulting from ischemic damage such as that seen with atherosclerosis. Alzheimer and Huntington diseases are not related to the vasculature and have a much longer onset. Frontotemporal dementia is a syndrome that includes primary progressive aphasia, corticobasal degeneration, progressive supranuclear palsy, and semantic dementias.

Assessment of genetic predisposition supports asking a client who is exhibiting symptoms of a delusional disorder what?

Whether any family members have been diagnosed with schizophrenia

A family member of a client diagnosed with Alzheimer disease asks the nurse what is causing the client's memory loss. Which neurotransmitter does the nurse identify that plays a role in memory loss in Alzheimer disease?

acetylcholine Acetylcholine (ACh) is an excitatory neurotransmitter that is involved with higher intellectual functioning and memory. Clients diagnosed with Alzheimer disease often have low ACh levels that cause the client's memory loss. Dopamine is an excitatory neurotransmitter that is involved with regulation of action, emotion, motivation, and attention. Serotonin is primarily an excitatory neurotransmitter that is involved with mood, cognition, sensory perceptions, sleep, and appetite. Histamine's functions are not well known, but it appears to have a role in automatic and neuroendocrine regulation.

The nurse is caring for a client with a brain abscess. Which cerebral structure would the nurse expect to be considered when medications are being identified to treat the client's infection?

blood-brain barrier The blood-brain barrier consists of unique capillary characteristics and the astrocytes, which are a type of neuroglial cell. The endothelial cells in the capillaries supplying brain neurons have tight or overlapping junctions, which decrease capillary permeability. This can slow and control the diffusion of most substances, except for water, carbon dioxide, and oxygen. The blood-brain barrier represents a therapeutic challenge to drug treatment of brain-related disorders because a large percentage of drugs are carried bound to plasma proteins and are unable to cross into the brain. The meninges is a membrane that covers the nerves in the brain and spine. The brain stem controls basic vital sign functions. The cerebellum coordinates motor function.

The parent of 3 1/2-year-old preschooler tells the nurse that the child argues quite a bit and says that the child is always right. The nurse interprets this information as indicating:

centering At age 3 years, cognitive development is still preoperational. Although children during this period do enter a second phase called intuitional thought, they lack insight to view themselves as others see them or put themselves in another's place. This is called centering. Because preschoolers cannot make this kind of mental substitution, they feel they are always right and causes them to argue. Conservation is reflected in the child's ability to distinguish that two items of equal size are the same despite a change in form. Initiative is the developmental task of preschoolers and is reflected in the child attempting to learn as much as possible about the world around them by trying new activities or having new experiences. Guilt occurs if children are punished or criticized for attempts at initiative.

An adult client diagnosed with a somatoform disorder is referred to therapy. Which therapy would the nurse anticipate the client is referred to?

cognitive-behavioral therapy (CBT) Clients with somatic symptom disorder and anxiety illness disorder who participated in a structured cognitive-behavioral group showed evidence of improved physical and emotional health. The overall goals of the group were offering peer support, sharing methods of coping, and perceiving and expressing emotions. Clients with hypochondriasis who were willing to participate in cognitive-behavioral therapy (CBT) and take medications were able to alter their erroneous perceptions of threat (of illness) and improve. CBT also produced significant improvement in clients with anxiety, depression, and somatization symptoms. Eye-movement desensitization and reprocessing (EMDR), exposure therapy, and dialectical-behavioral therapy (DBT) are not indicated for somatoform disorders.

A client has been recently diagnosed with Alzheimer disease and has been prescribed a cholinesterase inhibitor. This drug will slow the progression of the client's symptoms by:

decreasing ACh breakdown. Explanation: Acetylcholine is secreted by the cholinergic nerve endings and is rapidly broken down by the enzyme acetylcholinesterase. The cholinesterase inhibitor inhibits the breakdown of the neurotransmitter in the synaptic space, thereby increasing the effect of ACh. ACh levels do not affect action potentials in presynaptic or postsynaptic membranes.

A pregnant client who is taking risperidone, an antipsychotic prescribed for their bipolar disorder, is at high risk for developing which hormonal adverse effect?

excess prolactin secretion

The nurse is caring for a client suspected of ketamine abuse. What characteristic behavior would the nurse expect to observe?

sensory hallucinations Ketamine is a general anesthetic that is chemically related to PCP and used during induction or maintenance of general anesthesia. Ketamine causes distorted senses and perceptions as well as dissociative reactions. These effects produce a high risk of injuries. Abnormal strength, euphoria, and catatonia are not characteristic effects of this medication.

The terms "judgment" and "insight" are sometimes used incorrectly. Insight is the ability to:

understand the nature of one's problem or situation. Insight is the ability to understand a situation or problem and its effect on one's life. Judgment is the ability to make appropriate choices and behave in an appropriate manner. A client may be able to explain the psychiatric diagnosis but may lack the insight to understand the underlying problem and how it's affecting the client's life.