Question 1

The staff on a care area that has a high percentage of clients with confusion attends an educational program on delirium management.Which statement,made by a staff nurse,indicates that teaching has been effective?

Accepted Answer

A) The structure of the client's environment should support cognitive functions. Aids for hearing or vision are necessary to prevent sensory loss or distortion. Familiar objects from home, such as slippers, robe, and photographs, may help with orientation. Easily read clocks, orientation boards, and a structured routine that includes physical activity and socialization without sensory overload will also help with orientation. Clients with delirium can exhibit hyperactivity when overstimulated.
B) The structure of the client's environment should support cognitive functions. Aids for hearing or vision are necessary to prevent sensory loss or distortion. Familiar objects from home, such as slippers, robe, and photographs, may help with orientation. Easily read clocks, orientation boards, and a structured routine that includes physical activity and socialization without sensory overload will also help with orientation. Clients with delirium can exhibit hyperactivity when overstimulated.
C) The structure of the client's environment should support cognitive functions. Aids for hearing or vision are necessary to prevent sensory loss or distortion. Familiar objects from home, such as slippers, robe, and photographs, may help with orientation. Easily read clocks, orientation boards, and a structured routine that includes physical activity and socialization without sensory overload will also help with orientation. Clients with delirium can exhibit hyperactivity when overstimulated.
D) The structure of the client's environment should support cognitive functions. Aids for hearing or vision are necessary to prevent sensory loss or distortion. Familiar objects from home, such as slippers, robe, and photographs, may help with orientation. Easily read clocks, orientation boards, and a structured routine that includes physical activity and socialization without sensory overload will also help with orientation. Clients with delirium can exhibit hyperactivity when overstimulated.

Question 2

A client with Alzheimer disease is scheduled to attend occupational therapy three times a week.Which is the purpose of the client attending this type of therapy?

Accepted Answer

A) Individuals who are starting to experience language deficits may be able to slow this decline by working with a speech therapist. Physical therapy can help individuals improve their muscle tone, maintain coordination, and maintain their range of motion. Occupational therapy helps the client maintain the ability to perform many activities of daily living. Access to community organizations is facilitated through the use of social workers.
B) Individuals who are starting to experience language deficits may be able to slow this decline by working with a speech therapist. Physical therapy can help individuals improve their muscle tone, maintain coordination, and maintain their range of motion. Occupational therapy helps the client maintain the ability to perform many activities of daily living. Access to community organizations is facilitated through the use of social workers.
C) Individuals who are starting to experience language deficits may be able to slow this decline by working with a speech therapist. Physical therapy can help individuals improve their muscle tone, maintain coordination, and maintain their range of motion. Occupational therapy helps the client maintain the ability to perform many activities of daily living. Access to community organizations is facilitated through the use of social workers.
D) Individuals who are starting to experience language deficits may be able to slow this decline by working with a speech therapist. Physical therapy can help individuals improve their muscle tone, maintain coordination, and maintain their range of motion. Occupational therapy helps the client maintain the ability to perform many activities of daily living. Access to community organizations is facilitated through the use of social workers.

Question 3

The nurse identifies the diagnosis of Risk for Injury for a client who is disoriented.Which statement should the nurse identify as an expected outcome for this client's care?

Accepted Answer

A) The client "does not sustain injury during wanderings" is the correct answer because it relates to the diagnosis and is measurable. The client "maintains continence on four out of five voidings" does not relate to the diagnosis. The client "sleeps through the night and stays awake most of the day" does not relate to the diagnosis. The client "receives culturally appropriate care" is an incorrect answer because expected outcomes are unknown and not measurable.
B) The client "does not sustain injury during wanderings" is the correct answer because it relates to the diagnosis and is measurable. The client "maintains continence on four out of five voidings" does not relate to the diagnosis. The client "sleeps through the night and stays awake most of the day" does not relate to the diagnosis. The client "receives culturally appropriate care" is an incorrect answer because expected outcomes are unknown and not measurable.
C) The client "does not sustain injury during wanderings" is the correct answer because it relates to the diagnosis and is measurable. The client "maintains continence on four out of five voidings" does not relate to the diagnosis. The client "sleeps through the night and stays awake most of the day" does not relate to the diagnosis. The client "receives culturally appropriate care" is an incorrect answer because expected outcomes are unknown and not measurable.
D) The client "does not sustain injury during wanderings" is the correct answer because it relates to the diagnosis and is measurable. The client "maintains continence on four out of five voidings" does not relate to the diagnosis. The client "sleeps through the night and stays awake most of the day" does not relate to the diagnosis. The client "receives culturally appropriate care" is an incorrect answer because expected outcomes are unknown and not measurable.

Question 4

A student nurse is reviewing the pathophysiology and etiology of Alzheimer disease (AD).Which is true regarding the pathophysiology and etiology of this disease? Select all that apply.

Accepted Answer

A) In Alzheimer disease, the neuronal cells die in a characteristic order, beginning with neurons in the limbic system, including the hippocampus. There are two basic types of AD: familial and sporadic. Familial AD (FAD) has a strong inherited component and is also called early-onset AD because it usually manifests before age 65. Sporadic AD shows no clear pattern of inheritance, although genetic factors may be involved. Because it typically develops after age 65, sporadic AD is sometimes referred to as late-onset AD. Damage to the limbic system from AD results in memory loss and emotional problems.
B) In Alzheimer disease, the neuronal cells die in a characteristic order, beginning with neurons in the limbic system, including the hippocampus. There are two basic types of AD: familial and sporadic. Familial AD (FAD) has a strong inherited component and is also called early-onset AD because it usually manifests before age 65. Sporadic AD shows no clear pattern of inheritance, although genetic factors may be involved. Because it typically develops after age 65, sporadic AD is sometimes referred to as late-onset AD. Damage to the limbic system from AD results in memory loss and emotional problems.
C) In Alzheimer disease, the neuronal cells die in a characteristic order, beginning with neurons in the limbic system, including the hippocampus. There are two basic types of AD: familial and sporadic. Familial AD (FAD) has a strong inherited component and is also called early-onset AD because it usually manifests before age 65. Sporadic AD shows no clear pattern of inheritance, although genetic factors may be involved. Because it typically develops after age 65, sporadic AD is sometimes referred to as late-onset AD. Damage to the limbic system from AD results in memory loss and emotional problems.
D) In Alzheimer disease, the neuronal cells die in a characteristic order, beginning with neurons in the limbic system, including the hippocampus. There are two basic types of AD: familial and sporadic. Familial AD (FAD) has a strong inherited component and is also called early-onset AD because it usually manifests before age 65. Sporadic AD shows no clear pattern of inheritance, although genetic factors may be involved. Because it typically develops after age 65, sporadic AD is sometimes referred to as late-onset AD. Damage to the limbic system from AD results in memory loss and emotional problems.
E) In Alzheimer disease, the neuronal cells die in a characteristic order, beginning with neurons in the limbic system, including the hippocampus. There are two basic types of AD: familial and sporadic. Familial AD (FAD) has a strong inherited component and is also called early-onset AD because it usually manifests before age 65. Sporadic AD shows no clear pattern of inheritance, although genetic factors may be involved. Because it typically develops after age 65, sporadic AD is sometimes referred to as late-onset AD. Damage to the limbic system from AD results in memory loss and emotional problems.

Question 5

A non-English-speaking school-age client is hospitalized with encephalitis and is experiencing delirium.Which intervention promotes a therapeutic environment for this child and family?

Accepted Answer

A) Encouraging the family to remain at the bedside with the client will promote a therapeutic environment for a client experiencing delirium caused by encephalitis. All of the other interventions are important for the discharge planning of this client.
B) Encouraging the family to remain at the bedside with the client will promote a therapeutic environment for a client experiencing delirium caused by encephalitis. All of the other interventions are important for the discharge planning of this client.
C) Encouraging the family to remain at the bedside with the client will promote a therapeutic environment for a client experiencing delirium caused by encephalitis. All of the other interventions are important for the discharge planning of this client.
D) Encouraging the family to remain at the bedside with the client will promote a therapeutic environment for a client experiencing delirium caused by encephalitis. All of the other interventions are important for the discharge planning of this client.

Question 6

A nurse manager is educating a group of staff nurses on recognizing the differences between confusion and delirium.Which statements will the nurse manager include? Select all that apply.

Accepted Answer

A) Delirium is a reversible condition caused by an acute problem, such as infection, and can occur at any age. Dementia is a cognitive decline generally associated with an aging adult. Older adult men are at higher risk for developing delirium, not younger adult females. Also, young children are at greater risk for developing delirium than adolescents due to the fact that children's bodies are less equipped to cope with insults such as fever, infection, and toxin exposure.
B) Delirium is a reversible condition caused by an acute problem, such as infection, and can occur at any age. Dementia is a cognitive decline generally associated with an aging adult. Older adult men are at higher risk for developing delirium, not younger adult females. Also, young children are at greater risk for developing delirium than adolescents due to the fact that children's bodies are less equipped to cope with insults such as fever, infection, and toxin exposure.
C) Delirium is a reversible condition caused by an acute problem, such as infection, and can occur at any age. Dementia is a cognitive decline generally associated with an aging adult. Older adult men are at higher risk for developing delirium, not younger adult females. Also, young children are at greater risk for developing delirium than adolescents due to the fact that children's bodies are less equipped to cope with insults such as fever, infection, and toxin exposure.
D) Delirium is a reversible condition caused by an acute problem, such as infection, and can occur at any age. Dementia is a cognitive decline generally associated with an aging adult. Older adult men are at higher risk for developing delirium, not younger adult females. Also, young children are at greater risk for developing delirium than adolescents due to the fact that children's bodies are less equipped to cope with insults such as fever, infection, and toxin exposure.
E) Delirium is a reversible condition caused by an acute problem, such as infection, and can occur at any age. Dementia is a cognitive decline generally associated with an aging adult. Older adult men are at higher risk for developing delirium, not younger adult females. Also, young children are at greater risk for developing delirium than adolescents due to the fact that children's bodies are less equipped to cope with insults such as fever, infection, and toxin exposure.

Question 7

The nurse is explaining the difference between delirium and dementia to a family member of a client with confusion.Which statement is appropriate for the nurse to include?

Accepted Answer

A) Delirium is commonly experienced by older adults who are hospitalized. Delirium is an acute rapid-onset condition with an etiology that can be traced to a known cause. The cause of delirium can often be determined, and removal of the cause will usually result in complete recovery. The symptoms of delirium are not similar to those of depression.
B) Delirium is commonly experienced by older adults who are hospitalized. Delirium is an acute rapid-onset condition with an etiology that can be traced to a known cause. The cause of delirium can often be determined, and removal of the cause will usually result in complete recovery. The symptoms of delirium are not similar to those of depression.
C) Delirium is commonly experienced by older adults who are hospitalized. Delirium is an acute rapid-onset condition with an etiology that can be traced to a known cause. The cause of delirium can often be determined, and removal of the cause will usually result in complete recovery. The symptoms of delirium are not similar to those of depression.
D) Delirium is commonly experienced by older adults who are hospitalized. Delirium is an acute rapid-onset condition with an etiology that can be traced to a known cause. The cause of delirium can often be determined, and removal of the cause will usually result in complete recovery. The symptoms of delirium are not similar to those of depression.

Question 8

The client's family says,"We don't understand what is happening to Dad.He becomes very agitated in the evenings,cussing like a sailor." When responding to the family,which phenomenon will the nurse include?

Accepted Answer

A) Sundown syndrome, or sundowning, is understood as confused behavior when the environmental stimulation is low. It is seen in clients with delirium and dementia who are institutionalized. The client can become increasingly agitated, disoriented, or even aggressive/paranoid or impulsive and emotional later in the day and at night. Delirium is a rapid-onset type of confusion. Anxiety does not come and go; it is a state of mind. Psychosis is a mental disorder, and this client is not exhibiting signs of psychosis.
B) Sundown syndrome, or sundowning, is understood as confused behavior when the environmental stimulation is low. It is seen in clients with delirium and dementia who are institutionalized. The client can become increasingly agitated, disoriented, or even aggressive/paranoid or impulsive and emotional later in the day and at night. Delirium is a rapid-onset type of confusion. Anxiety does not come and go; it is a state of mind. Psychosis is a mental disorder, and this client is not exhibiting signs of psychosis.
C) Sundown syndrome, or sundowning, is understood as confused behavior when the environmental stimulation is low. It is seen in clients with delirium and dementia who are institutionalized. The client can become increasingly agitated, disoriented, or even aggressive/paranoid or impulsive and emotional later in the day and at night. Delirium is a rapid-onset type of confusion. Anxiety does not come and go; it is a state of mind. Psychosis is a mental disorder, and this client is not exhibiting signs of psychosis.
D) Sundown syndrome, or sundowning, is understood as confused behavior when the environmental stimulation is low. It is seen in clients with delirium and dementia who are institutionalized. The client can become increasingly agitated, disoriented, or even aggressive/paranoid or impulsive and emotional later in the day and at night. Delirium is a rapid-onset type of confusion. Anxiety does not come and go; it is a state of mind. Psychosis is a mental disorder, and this client is not exhibiting signs of psychosis.

Question 9

An older adult client,hospitalized post-surgery,wakes up in the middle of the night very confused.The nurse reorients the client to the surroundings and gets the client to return to sleep.Which should the nurse consider as a source for the client's confusion?

Accepted Answer

A) Certain medications, such as sleeping pills, tranquilizers, and pain medications, can cause symptoms similar to dementia. Therefore, the client's medication must be reviewed to determine the effects of drugs and cognitive changes. Although loss of a loved one may result in depression, it is unlikely to be the source of confusion. Age alone does not cause confusion, and cardiac disease alone would not cause confusion.
B) Certain medications, such as sleeping pills, tranquilizers, and pain medications, can cause symptoms similar to dementia. Therefore, the client's medication must be reviewed to determine the effects of drugs and cognitive changes. Although loss of a loved one may result in depression, it is unlikely to be the source of confusion. Age alone does not cause confusion, and cardiac disease alone would not cause confusion.
C) Certain medications, such as sleeping pills, tranquilizers, and pain medications, can cause symptoms similar to dementia. Therefore, the client's medication must be reviewed to determine the effects of drugs and cognitive changes. Although loss of a loved one may result in depression, it is unlikely to be the source of confusion. Age alone does not cause confusion, and cardiac disease alone would not cause confusion.
D) Certain medications, such as sleeping pills, tranquilizers, and pain medications, can cause symptoms similar to dementia. Therefore, the client's medication must be reviewed to determine the effects of drugs and cognitive changes. Although loss of a loved one may result in depression, it is unlikely to be the source of confusion. Age alone does not cause confusion, and cardiac disease alone would not cause confusion.

Question 10

The nurse plans a class about Alzheimer disease for a caregiver support group.Which should the nurse include when teaching this class of caregivers? Select all that apply.

Accepted Answer

A) Memory difficulties are an early symptom of Alzheimer disease. It is suspected that chronic inflammation and excess free radicals may cause neuron damage, which contributes to the disease. Depression and aggressive behavior are common symptoms of the disease. Alzheimer disease accounts for about 70% of all dementias. The acetylcholinesterase inhibitors, not the glutamatergic inhibitors, are the most widely used class of drugs for treating the disease.
B) Memory difficulties are an early symptom of Alzheimer disease. It is suspected that chronic inflammation and excess free radicals may cause neuron damage, which contributes to the disease. Depression and aggressive behavior are common symptoms of the disease. Alzheimer disease accounts for about 70% of all dementias. The acetylcholinesterase inhibitors, not the glutamatergic inhibitors, are the most widely used class of drugs for treating the disease.
C) Memory difficulties are an early symptom of Alzheimer disease. It is suspected that chronic inflammation and excess free radicals may cause neuron damage, which contributes to the disease. Depression and aggressive behavior are common symptoms of the disease. Alzheimer disease accounts for about 70% of all dementias. The acetylcholinesterase inhibitors, not the glutamatergic inhibitors, are the most widely used class of drugs for treating the disease.
D) Memory difficulties are an early symptom of Alzheimer disease. It is suspected that chronic inflammation and excess free radicals may cause neuron damage, which contributes to the disease. Depression and aggressive behavior are common symptoms of the disease. Alzheimer disease accounts for about 70% of all dementias. The acetylcholinesterase inhibitors, not the glutamatergic inhibitors, are the most widely used class of drugs for treating the disease.
E) Memory difficulties are an early symptom of Alzheimer disease. It is suspected that chronic inflammation and excess free radicals may cause neuron damage, which contributes to the disease. Depression and aggressive behavior are common symptoms of the disease. Alzheimer disease accounts for about 70% of all dementias. The acetylcholinesterase inhibitors, not the glutamatergic inhibitors, are the most widely used class of drugs for treating the disease.

Question 11

A nurse is caring for a client with Alzheimer disease (AD)who recently lost the ability to live independently but can still perform activities of daily living (ADLs).Which stage of the disease is this client in?

Accepted Answer

A) This client is in Stage 5 (moderate AD) because the client has lost the ability to live independently. In this stage, the client may be unable to choose appropriate clothing or prepare food and is at increased risk of someone taking advantage of him or her because of loss of cognition and lack of safety awareness. A client in Stage 3 (mild cognitive impairment) is able to maintain living independently, but the client's memory lapses are apparent to others. In Stage 6 (moderately severe AD), individuals become unable to perform even basic activities of daily living (ADLs).
B) This client is in Stage 5 (moderate AD) because the client has lost the ability to live independently. In this stage, the client may be unable to choose appropriate clothing or prepare food and is at increased risk of someone taking advantage of him or her because of loss of cognition and lack of safety awareness. A client in Stage 3 (mild cognitive impairment) is able to maintain living independently, but the client's memory lapses are apparent to others. In Stage 6 (moderately severe AD), individuals become unable to perform even basic activities of daily living (ADLs).
C) This client is in Stage 5 (moderate AD) because the client has lost the ability to live independently. In this stage, the client may be unable to choose appropriate clothing or prepare food and is at increased risk of someone taking advantage of him or her because of loss of cognition and lack of safety awareness. A client in Stage 3 (mild cognitive impairment) is able to maintain living independently, but the client's memory lapses are apparent to others. In Stage 6 (moderately severe AD), individuals become unable to perform even basic activities of daily living (ADLs).
D) This client is in Stage 5 (moderate AD) because the client has lost the ability to live independently. In this stage, the client may be unable to choose appropriate clothing or prepare food and is at increased risk of someone taking advantage of him or her because of loss of cognition and lack of safety awareness. A client in Stage 3 (mild cognitive impairment) is able to maintain living independently, but the client's memory lapses are apparent to others. In Stage 6 (moderately severe AD), individuals become unable to perform even basic activities of daily living (ADLs).

Question 12

A hospitalized older adult client suddenly does not recognize an adult daughter and states,"Why hasn't my wife come to see me?" The client's spouse has been dead for 5 years.Prior to the hospitalization,the client was clear of mind and thought.Which nursing diagnoses would be appropriate for this client? Select all that apply.

Accepted Answer

A) The client is experiencing acute confusion and impaired memory according to the scenario presented. The scenario does not indicate the client is experiencing anxiety or ineffective coping. Autonomic dysreflexia is a syndrome of clients with spinal cord damage, which is not indicated for this client.
B) The client is experiencing acute confusion and impaired memory according to the scenario presented. The scenario does not indicate the client is experiencing anxiety or ineffective coping. Autonomic dysreflexia is a syndrome of clients with spinal cord damage, which is not indicated for this client.
C) The client is experiencing acute confusion and impaired memory according to the scenario presented. The scenario does not indicate the client is experiencing anxiety or ineffective coping. Autonomic dysreflexia is a syndrome of clients with spinal cord damage, which is not indicated for this client.
D) The client is experiencing acute confusion and impaired memory according to the scenario presented. The scenario does not indicate the client is experiencing anxiety or ineffective coping. Autonomic dysreflexia is a syndrome of clients with spinal cord damage, which is not indicated for this client.
E) The client is experiencing acute confusion and impaired memory according to the scenario presented. The scenario does not indicate the client is experiencing anxiety or ineffective coping. Autonomic dysreflexia is a syndrome of clients with spinal cord damage, which is not indicated for this client.

Question 13

A client is diagnosed as having Stage 1 Alzheimer disease.Which are appropriate goals for the client and family at this time? Select all that apply.

Accepted Answer

A) Grieving over the diagnosis and loss of functioning and mental abilities will be an ongoing process for the client and the family members and is therefore a goal. While the client is still cognizant, it is important that the client and family discuss the desired treatment and designate a healthcare proxy to carry out the client's wishes regarding the treatment. Clients with early Alzheimer disease should start the cholinesterase inhibitor medication as soon as possible to extend the early stage of the disease. During this time period, the home environment should be modified to balance safety with client autonomy.
B) Grieving over the diagnosis and loss of functioning and mental abilities will be an ongoing process for the client and the family members and is therefore a goal. While the client is still cognizant, it is important that the client and family discuss the desired treatment and designate a healthcare proxy to carry out the client's wishes regarding the treatment. Clients with early Alzheimer disease should start the cholinesterase inhibitor medication as soon as possible to extend the early stage of the disease. During this time period, the home environment should be modified to balance safety with client autonomy.
C) Grieving over the diagnosis and loss of functioning and mental abilities will be an ongoing process for the client and the family members and is therefore a goal. While the client is still cognizant, it is important that the client and family discuss the desired treatment and designate a healthcare proxy to carry out the client's wishes regarding the treatment. Clients with early Alzheimer disease should start the cholinesterase inhibitor medication as soon as possible to extend the early stage of the disease. During this time period, the home environment should be modified to balance safety with client autonomy.
D) Grieving over the diagnosis and loss of functioning and mental abilities will be an ongoing process for the client and the family members and is therefore a goal. While the client is still cognizant, it is important that the client and family discuss the desired treatment and designate a healthcare proxy to carry out the client's wishes regarding the treatment. Clients with early Alzheimer disease should start the cholinesterase inhibitor medication as soon as possible to extend the early stage of the disease. During this time period, the home environment should be modified to balance safety with client autonomy.

Question 14

A client with schizophrenia is unable to complete activities of daily living.The client does not respond much to what is happening,and lacks interest in the environment.Based on this data,which conclusion by the nurse is appropriate?

Accepted Answer

A) Negative symptoms are those that subtract from normal behavior. These symptoms include a lack of interest, motivation, responsiveness, pleasure in daily activities, or the ability to care for self. Positive symptoms include hallucinations, delusions, and a disorganized thought or speech pattern. There isn't any evidence to support that the client is hearing voices. There isn't any evidence to support that the client is very depressed.
B) Negative symptoms are those that subtract from normal behavior. These symptoms include a lack of interest, motivation, responsiveness, pleasure in daily activities, or the ability to care for self. Positive symptoms include hallucinations, delusions, and a disorganized thought or speech pattern. There isn't any evidence to support that the client is hearing voices. There isn't any evidence to support that the client is very depressed.
C) Negative symptoms are those that subtract from normal behavior. These symptoms include a lack of interest, motivation, responsiveness, pleasure in daily activities, or the ability to care for self. Positive symptoms include hallucinations, delusions, and a disorganized thought or speech pattern. There isn't any evidence to support that the client is hearing voices. There isn't any evidence to support that the client is very depressed.
D) Negative symptoms are those that subtract from normal behavior. These symptoms include a lack of interest, motivation, responsiveness, pleasure in daily activities, or the ability to care for self. Positive symptoms include hallucinations, delusions, and a disorganized thought or speech pattern. There isn't any evidence to support that the client is hearing voices. There isn't any evidence to support that the client is very depressed.

Question 15

A nurse is caring for a client who is confused and agitated.The nurse understands that the best method to determine if the client has reversible confusion is to use the Confusion Assessment Method (CAM).What is true regarding this diagnostic tool?

Accepted Answer

A) The Confusion Assessment Method (CAM) is a tool the nurse can use to differentiate between delirium and dementia. It consists of two parts; the first part screens for cognitive impairment and the second part screens for reversible confusion. Although it is effective in differentiating between delirium and dementia, it does not measure the severity of the client's delirium and it does not screen for depression.
B) The Confusion Assessment Method (CAM) is a tool the nurse can use to differentiate between delirium and dementia. It consists of two parts; the first part screens for cognitive impairment and the second part screens for reversible confusion. Although it is effective in differentiating between delirium and dementia, it does not measure the severity of the client's delirium and it does not screen for depression.
C) The Confusion Assessment Method (CAM) is a tool the nurse can use to differentiate between delirium and dementia. It consists of two parts; the first part screens for cognitive impairment and the second part screens for reversible confusion. Although it is effective in differentiating between delirium and dementia, it does not measure the severity of the client's delirium and it does not screen for depression.
D) The Confusion Assessment Method (CAM) is a tool the nurse can use to differentiate between delirium and dementia. It consists of two parts; the first part screens for cognitive impairment and the second part screens for reversible confusion. Although it is effective in differentiating between delirium and dementia, it does not measure the severity of the client's delirium and it does not screen for depression.

Question 16

The family of an older adult client is informed that the client has delirium.Which statement indicates that the family understands the diagnosis?

Accepted Answer

A) Delirium is characterized by a rapid and abrupt onset of symptoms. Although delirium is more common in older individuals, aging is not a cause of delirium. Impairments in short-term memory are more indicative of dementia. The fact that he had been independent has no bearing on his current symptoms.
B) Delirium is characterized by a rapid and abrupt onset of symptoms. Although delirium is more common in older individuals, aging is not a cause of delirium. Impairments in short-term memory are more indicative of dementia. The fact that he had been independent has no bearing on his current symptoms.
C) Delirium is characterized by a rapid and abrupt onset of symptoms. Although delirium is more common in older individuals, aging is not a cause of delirium. Impairments in short-term memory are more indicative of dementia. The fact that he had been independent has no bearing on his current symptoms.
D) Delirium is characterized by a rapid and abrupt onset of symptoms. Although delirium is more common in older individuals, aging is not a cause of delirium. Impairments in short-term memory are more indicative of dementia. The fact that he had been independent has no bearing on his current symptoms.

Question 17

The family of a school-age client is very upset because the child does not seem to know the family.The client has been admitted with pneumonia and has a high fever.What should the nurse teach this family to alleviate stress about the child's confusion? Select all that apply.

Accepted Answer

A) The nurse will want to explain that high fever can cause confusion in the child and that this symptom will abate when the temperature returns to normal. Having the family remain at the bedside will decrease anxiety felt by the family. Teaching the family how to care for the child during the hospitalization or upon discharge will not necessarily decrease their anxiety. Telling the family the confusion will not last long is not helping them to understand the nature of the symptom.
B) The nurse will want to explain that high fever can cause confusion in the child and that this symptom will abate when the temperature returns to normal. Having the family remain at the bedside will decrease anxiety felt by the family. Teaching the family how to care for the child during the hospitalization or upon discharge will not necessarily decrease their anxiety. Telling the family the confusion will not last long is not helping them to understand the nature of the symptom.
C) The nurse will want to explain that high fever can cause confusion in the child and that this symptom will abate when the temperature returns to normal. Having the family remain at the bedside will decrease anxiety felt by the family. Teaching the family how to care for the child during the hospitalization or upon discharge will not necessarily decrease their anxiety. Telling the family the confusion will not last long is not helping them to understand the nature of the symptom.
D) The nurse will want to explain that high fever can cause confusion in the child and that this symptom will abate when the temperature returns to normal. Having the family remain at the bedside will decrease anxiety felt by the family. Teaching the family how to care for the child during the hospitalization or upon discharge will not necessarily decrease their anxiety. Telling the family the confusion will not last long is not helping them to understand the nature of the symptom.
E) The nurse will want to explain that high fever can cause confusion in the child and that this symptom will abate when the temperature returns to normal. Having the family remain at the bedside will decrease anxiety felt by the family. Teaching the family how to care for the child during the hospitalization or upon discharge will not necessarily decrease their anxiety. Telling the family the confusion will not last long is not helping them to understand the nature of the symptom.

Question 18

A nurse is caring for a client with Alzheimer disease (AD)who has receptive aphasia.Which area of the brain is likely damaged from AD?

Accepted Answer

A) Damage to the client's temporal lobe causes receptive aphasia. Damage to the limbic system manifests as loss of memory, fluctuating emotions, depression, and difficulty learning new things. Damage to the frontal lobe manifests as problems with intentional movement, fluctuating emotions, and loss of the ability to walk. Frontal lobe damage causes loss of the ability to talk and the ability to swallow. Damage to the occipital lobe results in loss of reading comprehension and hallucinations.
B) Damage to the client's temporal lobe causes receptive aphasia. Damage to the limbic system manifests as loss of memory, fluctuating emotions, depression, and difficulty learning new things. Damage to the frontal lobe manifests as problems with intentional movement, fluctuating emotions, and loss of the ability to walk. Frontal lobe damage causes loss of the ability to talk and the ability to swallow. Damage to the occipital lobe results in loss of reading comprehension and hallucinations.
C) Damage to the client's temporal lobe causes receptive aphasia. Damage to the limbic system manifests as loss of memory, fluctuating emotions, depression, and difficulty learning new things. Damage to the frontal lobe manifests as problems with intentional movement, fluctuating emotions, and loss of the ability to walk. Frontal lobe damage causes loss of the ability to talk and the ability to swallow. Damage to the occipital lobe results in loss of reading comprehension and hallucinations.
D) Damage to the client's temporal lobe causes receptive aphasia. Damage to the limbic system manifests as loss of memory, fluctuating emotions, depression, and difficulty learning new things. Damage to the frontal lobe manifests as problems with intentional movement, fluctuating emotions, and loss of the ability to walk. Frontal lobe damage causes loss of the ability to talk and the ability to swallow. Damage to the occipital lobe results in loss of reading comprehension and hallucinations.

Question 19

A home health nurse visits a client with Stage 2 Alzheimer disease who lives at home with a spouse.Which action by the nurse enhances the spouse's ability to meet the needs of the client?

Accepted Answer

A) Stage 2 clients are generally more confused, can demonstrate repetitive behavior, are less able to make simple decisions and to adapt to environmental changes, and are often unable to carry out activities of daily living. The spouse needs opportunities to have breaks from the demands of the client's care and should be encouraged to take rest periods and avoid fatigue. Because the Stage 2 client does not adapt well to changes in the environment, it would be best to have someone come into the home, rather than to have the client go out. An outing or a list of activities would be better suited for the client in Stage 1. Recommending placement in long-term care might be premature, and is not up to the nurse.
B) Stage 2 clients are generally more confused, can demonstrate repetitive behavior, are less able to make simple decisions and to adapt to environmental changes, and are often unable to carry out activities of daily living. The spouse needs opportunities to have breaks from the demands of the client's care and should be encouraged to take rest periods and avoid fatigue. Because the Stage 2 client does not adapt well to changes in the environment, it would be best to have someone come into the home, rather than to have the client go out. An outing or a list of activities would be better suited for the client in Stage 1. Recommending placement in long-term care might be premature, and is not up to the nurse.
C) Stage 2 clients are generally more confused, can demonstrate repetitive behavior, are less able to make simple decisions and to adapt to environmental changes, and are often unable to carry out activities of daily living. The spouse needs opportunities to have breaks from the demands of the client's care and should be encouraged to take rest periods and avoid fatigue. Because the Stage 2 client does not adapt well to changes in the environment, it would be best to have someone come into the home, rather than to have the client go out. An outing or a list of activities would be better suited for the client in Stage 1. Recommending placement in long-term care might be premature, and is not up to the nurse.
D) Stage 2 clients are generally more confused, can demonstrate repetitive behavior, are less able to make simple decisions and to adapt to environmental changes, and are often unable to carry out activities of daily living. The spouse needs opportunities to have breaks from the demands of the client's care and should be encouraged to take rest periods and avoid fatigue. Because the Stage 2 client does not adapt well to changes in the environment, it would be best to have someone come into the home, rather than to have the client go out. An outing or a list of activities would be better suited for the client in Stage 1. Recommending placement in long-term care might be premature, and is not up to the nurse.

Question 20

The nurse is reviewing content provided to a caregiver of an individual with Alzheimer disease.Which statement indicates that teaching has been effective?

Accepted Answer

A) The earlier the medications are started, the greater the effect they will have on the symptoms of Alzheimer disease. Current medications will only decrease symptoms for a short period of time. Drugs will not control symptoms for many years. The drugs for treatment of Alzheimer disease are no more dangerous than other drugs used for a long period of time.
B) The earlier the medications are started, the greater the effect they will have on the symptoms of Alzheimer disease. Current medications will only decrease symptoms for a short period of time. Drugs will not control symptoms for many years. The drugs for treatment of Alzheimer disease are no more dangerous than other drugs used for a long period of time.
C) The earlier the medications are started, the greater the effect they will have on the symptoms of Alzheimer disease. Current medications will only decrease symptoms for a short period of time. Drugs will not control symptoms for many years. The drugs for treatment of Alzheimer disease are no more dangerous than other drugs used for a long period of time.
D) The earlier the medications are started, the greater the effect they will have on the symptoms of Alzheimer disease. Current medications will only decrease symptoms for a short period of time. Drugs will not control symptoms for many years. The drugs for treatment of Alzheimer disease are no more dangerous than other drugs used for a long period of time.

Quiz 23: Cognition