Psych Week 8
Which statement made by the nurse would be most appropriate to an 89-year-old client who is confused but has no history of dementia and is hospitalized for an acute urinary tract infection?
"I know things are upsetting and confusing right now, but your confusion should clear as you get better." Rationale: "I know things are upsetting and confusing right now, but your confusion should clear as you get better," would be validating and giving information and would provide realistic reassurance to the client who has delirium. "You are likely to become progressively more confused now," is inaccurate as the person likely has delirium, and this will be an acute and temporary situation. "This should be just a temporary situation" provides some reassurance but no validation. "Don't worry about it; everyone is confused when they are in the hospital" is inaccurate and downplays the client's concern.
A 73-year-old client has been brought to the emergency department by the client's adult children due to abrupt and uncharacteristic changes in behavior, including impairments of memory and judgment. The subsequent history and diagnostic testing have resulted in a diagnosis of delirium. Which teaching point about the client's diagnosis should the nurse provide to the family?
"If the underlying cause of delirium is identified and treated, most people return to their previous level of functioning." Rationale: Delirium is characterized by reversibility, but this does not mean that treatment is not required or that spontaneous resolution occurs. Delirium is never considered a normal, age-related change.
A nurse is caring for a client with delirium who is experiencing illusions. Which interventions will the nurse provide for this client to promote a safe environment?
Ensure the room is well lit and it is without glare or shadows and limited noise. Rationale: Clients with delirium have difficulty paying attention, are easily distracted and disoriented, and may have sensory disturbances such as illusions, misinterpretations, or hallucinations. A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a client with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations.
A client was admitted to an inpatient unit with a diagnosis of dementia. A nursing assessment and interview of the client would include what?
Intellectual ability, health history, and self-care ability Rationale: A comprehensive nursing assessment should include obtaining the premorbid intellectual ability, health history, and self-care abilities of the client. The medical assessments, which are important, are not as critical to nursing assessment as the actions in the correct answer. Exploring early parent-child conflict and relational patterns would not be helpful with the dementive process.
The nurse manager in an long-term care facility is managing the environment to give optimal care to clients with dementia. Which will the nurse include when improving the living environment?
Plan for the same staff to provide care to individuals as much as possible. Rationale: Providing the same caregiver establishes familiarity and routine and can provide reassurance to clients with dementia. Open doors pose a safety risk of wandering away. Buffet-style meals require the client to make too many choices, thus adding to frustration. Clients are often quite willing to participate in physical activities but cannot initiate, plan, or carry out those activities without assistance.
The nurse is performing an assessment for a client with early signs of dementia. The nurse asks the client what they ate for breakfast this morning. Which assessment data will the nurse obtain and document from this question?
Recent memory Rationale: The initial sign of dementia is memory loss for recent events that exceeds normal forgetfulness. Asking what the client ate for breakfast is not determining orientation, food preferences, or remote memory.
The nurse has been working with a client following the sudden death of her husband in a work accident. The client initiated counseling because she didn't know how to cope with this crisis and felt totally overwhelmed. The nurse and client set goals for their working relationship to include which of the following?
The client feeling like she is gradually moving toward coping with the loss Rationale: The overall goal of crisis intervention is to help the client to re-establish equilibrium. To reach that end, the supporting goals include establishing a working relationship with the nurse, identifying the specific problem, reducing the distortion of her perception of the event, improving self-esteem, decreasing anxiety, establishing a support system, and using healthy coping mechanisms.
A 74-year-old is being seen in the mental health clinic. The client has never fully regained the level of activity the client had prior to the death of the client's spouse. The client continues to have symptoms of depression and has not been able to work or volunteer. In addition, the client complains of "anxiety attacks" that occur nearly every night. What type of grief reaction is this client exhibiting?
The client is experiencing complicated grieving reaction. The client needs to have a comprehensive mental health assessment. Rationale: In the case of complicated grief, it is important to treat as soon as possible. Unresolved grieving can lead to other psychological, as well as physical, problems if left untreated. Even in the case of extensive family support, medications are often needed to assist the individual to recover completely from this type of grief reaction.
A nurse working in an assisted living facility is holding an inservice for the nursing assistants. The nurse reviews common behaviors associated with cognitive deterioration associated with dementia. Which would cause the nurse to know that the assistants correctly understood if it were expressed during a posttest?
The clients may not recognize their family when they come to visit. Rationale: Dementia is a mental disorder that involves multiple cognitive deficits, primarily memory impairment. Failing to recognize a family member would be an indication of serious memory impairment. Clients can often not express their needs, conduct ADLs or schedule their time.
The nurse is working with the family of a client who is newly diagnosed with Alzheimer's type dementia. Which suggestion would be effective for assisting the family members in daily orienting of their family member when the client returns home?
Use daily newspapers, calendars, and a set routine. Rationale: Using daily newspapers, calendars, and a set, unchanging routine would be a more effective way to provide daily orientation for the family member. Changing daily activities would make it more difficult to maintain orientation. Reading to the client for long periods of time would not maintain client involvement and appropriate stimulation. Using daily quizzes would place stressful demands on the client and not provide functionally appropriate tasks.
The nurse caring for an older adult client with dementia asks the client's children to bring old photo albums when they visit. Which best describes the benefit of viewing photos when caring for the client?
Viewing photos is a form of reminiscence therapy for the client. Rationale: Reminiscence therapy (thinking about or relating personally significant past experiences) is an effective intervention for clients with dementia. Rather than lamenting that the client is "living in the past," this therapy encourages family and caregivers also to reminisce with the client. Reminiscing uses the client's remote memory, which is not affected as severely or quickly as recent or immediate memory. Sharing photos may promote interaction, but the main benefit is in terms of the client's own cognition.
While assessing for intimate partner violence, the nurse learns that a client has not seen immediate family members for several years because the visits would upset the client's spouse. On which potential issue should the nurse focus with this client?
social isolation Rationale: Many perpetrators of intimate partner violence isolate their family from all social contacts, including other relatives. Revictimization refers to exposure to abuse or intimate partner violence later in life after experiencing the abuse or violence as a child. Women who have young children and depend on the perpetrator financially may believe that they cannot leave the abusive relationship. Those who are emotionally dependent on the perpetrator may experience an intense grief reaction that further complicates their leaving.
