Question 1

A new nurse asks what the difference is between dementia and delirium. The best response is:

Accepted Answer

While both dementia and delirium involve cognitive impairment, there are key differences. Delirium is typically an acute, temporary state of confusion that can occur suddenly, often in hospitalized or medically ill clients over the age of 60. It can be caused by a variety of factors such as medication side effects, infections, or metabolic imbalances. In contrast, dementia is a progressive, chronic condition that involves a decline in memory, thinking, and behavior over time. Knowing these differences is important for nurses as they assess and care for their patients.

Question 2

When a client with memory loss is in need of orienting cues, the most appropriate response for maintaining dignity and self-esteem would be:

Accepted Answer

Option C is the best choice as it provides an orienting cue (the date) in a non-patronizing manner. It also acknowledges the present situation without bringing attention to the client's memory loss or implying that they should have remembered information from the past (as seen in options A and B). Option D may seem empathetic but it does not provide an orienting cue and may actually confuse or frustrate the client.

Question 3

A 73-year-old widower was brought into the emergency room by his son. The client has congestive heart failure but is under the care of a physician and has been in good health. The son had been called by the fire department after they put out a small cooking fire at the client's home. The firefighters reported that they had found the client sitting in a chair mumbling incoherently, unaware of the fire and smoke. The client now appears to be drifting in and out of consciousness and is having problems keeping his attention on any one task. In this situation, The client is
Probably suffering from:

Accepted Answer

The client's sudden onset of confusion, incoherent mumbling, lack of awareness of his surroundings, and difficulty focusing on tasks are all signs of delirium. This acute change in mental status is often brought on by an underlying medical condition, such as infection or metabolic disorders, and can be life-threatening. It is important for the healthcare team to identify and treat the underlying cause of delirium as soon as possible to prevent further deterioration of the client's condition.

Question 4

Creutzfeldt Jakob disease is thought to be caused by:

Accepted Answer

Creutzfeldt Jakob disease is caused by an infection caused by a prion, a protein that can fold abnormally and cause damage to the brain. It is not caused by a genetic disorder, response to medications, or ischemic vascular disease.

Question 5

The dementia unit nursing staff are informed that the entire unit will be redecorated in the next 2 weeks. Nursing staff tell the nurse manager that this will be a problem for the clients. What particular client need is addressed by their concern?

Accepted Answer

The concern raised by the nursing staff indicates that they understand the importance of providing a stable and familiar environment for clients with dementia. Renovations and changes to the physical environment can be distressing and disorienting for this population, as they rely heavily on routine and familiarity for comfort and safety.

Question 6

A 79-year-old woman suffering from dementia of the Alzheimer's type resides in an independent living long-term care facility. During a recent nursing visit, the client was quite upset about the loss of her frying pan. While the client was complaining about its loss, she was holding the pan in her hand. The nurse pointed out to the client that she had the pan she was looking for. The client looked at the pan and stated, "No, this is not it." The nurse knows the client is exhibiting:

Accepted Answer

The client's behavior of holding the frying pan and not recognizing it as the object she was looking for is a classic example of agnosia, which is the inability to recognize familiar objects despite intact sensory abilities. Nystagmus is an involuntary eye movement, aphasia is a language disorder, and apraxia is the inability to carry out purposeful movements despite intact sensory and motor abilities, none of which are exhibited in this scenario.

Question 7

A nursing student expresses a belief that it is normal for older adults to experience forgetfulness and depression. The staff nurse should respond with which of the following statements?

Accepted Answer

Memory impairments and a depressed mood in older adults are not considered normal aging processes and may indicate underlying pathologies that require professional intervention. Aging does not inherently cause significant memory loss or depression, and these symptoms should be evaluated by healthcare professionals.

Question 8

What is the recommendation for environmental safety when clients have poor judgment?

Accepted Answer

Turning down the temperature on the hot water heater is a safety measure to prevent burns, which is important for clients with poor judgment who may not recognize the danger of hot water.

Question 9

The client's family says, "We don't understand what is happening to Dad. He seems better earlier in the day and then in the evening his confusion and agitation really increase." What is the best explanation for what the client is experiencing?

Accepted Answer

Sundowner syndrome is a condition where a person experiences increased confusion, agitation, and restlessness in the evening or at night. It is typically seen in people with dementia or other cognitive impairments.

Question 10

A common symptom of dementia is difficulty in recalling words. This is called:

Accepted Answer

Aphasia refers to difficulty in recalling words or expressing oneself through language, which is a common symptom of dementia. Apraxia refers to difficulty in carrying out coordinated movements, agnosia refers to difficulty in recognizing objects or people, and dysphagia refers to difficulty swallowing.

Question 11

A family member expresses concern to the nurse about behavioral changes in an elderly client. What information would cause the nurse to suspect a dementia disorder?

Accepted Answer

Problems with activities of daily living (such as preparing a meal or balancing a checkbook) are often early signs of dementia. The other options could be related to a variety of conditions, not just dementia.

Question 12

A client's daughter provides all the day-to-day care for her mother who has a diagnosis of dementia. The daughter is experiencing symptoms of insomnia, stomach pains, and frequent headaches. These symptoms may indicate that the daughter is in need of:

Accepted Answer

The daughter is likely experiencing symptoms of caregiver stress and burnout. Supportive counseling and information about respite care can help alleviate her symptoms and provide her with the assistance she needs to continue caring for her mother. A nursing home placement may not be necessary or desired, and electroconvulsive treatment or a thorough mental status examination may not be indicated at this time.

Question 13

In a supervision session, several of the nurses discuss methods for preventing agitated and angry outbursts in clients diagnosed with dementia. One nurse appropriately suggests:

Accepted Answer

Distraction and engagement in high-energy activities may actually increase agitation. Ignoring the behavior may escalate it. Attempting a rational discussion with the client is unlikely to be effective in dealing with their dementia-related behavior. Distraction or a quieter environment at the first sign of agitation is the most appropriate choice, as it can prevent escalation of agitated behavior in clients with dementia.

Question 14

A 70-year-old client is being evaluated for dementia. Assessment indicates the client is able to recall childhood memories and some recent events, has poor self-care skills, and cries much of the day. What is the appropriate diagnosis?

Accepted Answer

The symptoms described, such as the ability to recall memories but with poor self-care skills and frequent crying, are more indicative of depression than dementia. Depression in the elderly can often mimic dementia (sometimes referred to as pseudodementia), but the presence of emotional symptoms like frequent crying points more towards a mood disorder.

Question 15

In planning care for a person with dementia, what is the most important consideration?

Accepted Answer

Focusing on strengths and abilities is important because this allows the person with dementia to maintain a sense of independence and dignity. It can also help to reduce barriers to communication and improve overall quality of life. While identifying problems and ensuring medications are taken are also important, they should be addressed in conjunction with strengths and abilities. It may be necessary to discuss end-of-life issues at some point, but this should not be the most important consideration when planning care for someone with dementia.

Question 16

A nurse is working with a family who is caring for their mother at home. They complain that the strain of caring for her 24 hours a day is exhausting them. What is the nurse's best suggestion?

Accepted Answer

Obtaining respite care would allow the family to take a break from caring for their mother while ensuring that she still receives proper care. Family therapy may be helpful, but it does not address the immediate need for respite care. Placing their mother in a nursing home may not be the best option if the family wishes to continue caring for her at home. Hiring a housekeeper may be helpful for household tasks, but would not necessarily alleviate the strain of providing 24-hour care.

Question 17

Delirium poses a serious threat to a client's:

Accepted Answer

Delirium causes confusion, disorientation, and changes in mood and behavior that can put the client's safety and dignity at risk. Therefore, option B is the best choice.

Question 18

A nurse is meeting with a family in which the wife abuses alcohol. During the family assessment meeting, the nurse observes that the husband tends to help the wife during the assessment. The husband says, "I help her a lot. This is so difficult for her." What type of support group might be helpful for the husband?

Accepted Answer

The answer of A nurse is meeting with a family...

Question 19

Which is the priority intervention for a client admitted with acute alcohol intoxication?

Accepted Answer

Monitoring vital signs frequently is the priority intervention for a client admitted with acute alcohol intoxication as it helps to identify any potential complications such as respiratory depression or aspiration. Darkening the room and checking for seizure precaution equipment may be necessary interventions, but they are not as urgent as monitoring vital signs. Restraint should only be used as a last resort for safety reasons if the client becomes a danger to themselves or others.

Question 20

The nurse is taking the history of a psychiatric client suspected of abusing alcohol. Which assessment question is best to ask?

Accepted Answer

Asking "When was your last drink?" is a direct and non-judgmental question that can help determine recent alcohol use and potential withdrawal risk.

Quiz 2: Psychiatric-Mental Health Nursing Processes, and Clients With Mental Disorders