Chapter 23 - Neurocognitive Disorders

Question 1

An older adult client takes multiple medications daily. Over 2 days, the client developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What are these findings most characteristic of?

a. delirium.
b. dementia.
c. amnestic syndrome.
d. Alzheimer’s disease.

Answer 1

a. delirium.

Question 2

A client with fluctuating levels of awareness, confusion, and disturbed orientation shouts, “Bugs are crawling on my legs. Get them off!” Which problem is the client experiencing?

a. Aphasia
b. Dystonia
c. Tactile hallucinations
d. Mnemonic disturbance

Answer 2

c. Tactile hallucinations

Question 3

A client with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, “Someone get these bugs off me.” What is the nurse’s best response?

a. “No bugs are on your legs. You are having hallucinations.”
b. “I will have someone stay here and brush off the bugs for you.”
c. “Try to relax. The crawling sensation will go away sooner if you can relax.”
d. “I don’t see any bugs, but I can tell you are frightened. I will stay with you.”

Answer 3

d. “I don’t see any bugs, but I can tell you are frightened. I will stay with you.”

Question 4

What is the priority nursing diagnosis for a client with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?

a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment
b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks
c. Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations
d. Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations

Answer 4

a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment

Question 5

What is the priority intervention for a client diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations?

a. Distraction using sensory stimulation
b. Careful observation and supervision
c. Avoidance of physical contact
d. Activation of the bed alarm

Answer 5

b. Careful observation and supervision

Question 6

A client diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this client?

a. Provide a well-lit room without glare or shadows. Limit noise and stimulation.
b. Maintain soft lighting day and night. Keep a radio on low volume continuously.
c. Light the room brightly day and night. Awaken the client hourly to assess mental status.
d. Keep the client by the nurse’s desk while awake. Provide rest periods in a room with a television on.

Answer 6

a. Provide a well-lit room without glare or shadows. Limit noise and stimulation.

Question 7

Which assessment finding would be likely for a client experiencing a hallucination?

a. The client looks at shadows on a wall and says, “I see scary faces.”
b. The client states, “I feel bugs crawling on my legs and biting me.”
c. The client reports telepathic messages from the television.
d. The client speaks in rhymes.

Answer 7

b. The client states, “I feel bugs crawling on my legs and biting me.”

Question 8

Consider these cerebral pathophysiologies: Lewy body development, frontotemporal degeneration, and accumulation of protein b-amyloid. Which diagnosis applies?

a. Cyclothymia
b. Dementia
c. Delirium
d. Amnesia

Answer 8

b. Dementia

Question 9

Which medication prescribed to clients diagnosed with Alzheimer’s disease antagonizes N-methyl-D-aspartate (NMDA) channels rather than cholinesterase?

a. Donepezil
b. Rivastigmine
c. Memantine
d. Galantamine

Answer 9

c. Memantine

Question 10

An older adult was stopped by police for driving through a red light. When asked for a driver’s license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident?

a. Aphasia
b. Apraxia
c. Agnosia
d. Anhedonia

Answer 10

c. Agnosia

Question 11

An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police intervened, they found that this adult was wearing a heavy coat and hat, even though it was July. Which stage of Alzheimer’s disease is evident?

a. Sundowning
b. Early
c. Middle
d. Late

Answer 11

c. Middle

Question 12

Consider these phenomena: accumulation of b-amyloid outside the neurons, neurofibrillary tangles, and neuronal degeneration in the hippocampus. Which health problem corresponds to these events?

a. Huntington’s disease
b. Alzheimer’s disease
c. Parkinson’s disease
d. Vascular dementia

Answer 12

b. Alzheimer’s disease

Question 13

A client diagnosed as mild stage Alzheimer’s disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the client cannot remember what to buy. Which nursing diagnosis applies at this time?

a. Self-care deficit
b. Impaired memory
c. Caregiver role strain
d. Adult failure to thrive

Answer 13

b. Impaired memory

Question 14

A client has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment?

a. Assist the client to perform simple tasks by giving step-by-step directions.
b. Reduce frustration by performing activities of daily living for the client.
c. Stimulate intellectual function by discussing new topics with the client.
d. Read one story from the newspaper to the client every day.

Answer 14

a. Assist the client to perform simple tasks by giving step-by-step directions.

Question 15

Two clients in a residential care facility are diagnosed with dementia. One shouts to the other, “Move along, you’re blocking the road.” The other client turns, shakes a fist, and shouts, “You’re trying to steal my car.” What is the nurse’s best action?

a. Administer one dose of an antipsychotic medication to both clients.
b. Reinforce reality. Say to the clients, “Walk along in the hall. This is not a traffic intersection.”
c. Separate and distract the clients. Take one to the day room and the other to an activities area.
d. Step between the two clients and say, “Please quiet down. We do not allow violence here.”

Answer 15

c. Separate and distract the clients. Take one to the day room and the other to an activities area.

Question 16

An older adult client in the intensive care unit is experiencing visual illusions. Which intervention will be most helpful?

a. Apply the client’s glasses.
b. Place personally meaningful objects in view.
c. Position large clocks and calendars on the wall.
d. Assure that the room is brightly lit but very quiet at all times.

Answer 16

a. Apply the client’s glasses.

Question 17

A client diagnosed with Alzheimer’s disease calls the fire department saying, “My smoke detectors are going off.” Firefighters investigate and discover that the client misinterpreted the telephone ringing. Which problem is this client experiencing?

a. Hyperorality
b. Aphasia
c. Apraxia
d. Agnosia

Answer 17

d. Agnosia

Question 18

During morning care, a nurse asks a client diagnosed with dementia, “How was your night?” The client replies, “It was lovely. I went out to dinner and a movie with my friend.” Which term applies to the client’s response?

a. Sundown syndrome
b. Confabulation
c. Perseveration
d. Delirium

Answer 18

b. Confabulation

Question 19

A nurse counsels the family of a client diagnosed with Alzheimer’s disease who lives at home and wanders at night. Which action is most important for the nurse to recommend for enhancing safety?

a. Apply a medical alert bracelet to the client.
b. Place locks at the tops of doors.
c. Discourage daytime napping.
d. Obtain a bed with side rails.

Answer 19

b. Place locks at the tops of doors.

Question 20

What should the goals of care for an older adult client diagnosed with delirium caused by fever and dehydration focus on?

a. returning to premorbid levels of function.
b. identifying stressors negatively affecting self.
c. demonstrating motor responses to noxious stimuli.
d. exerting control over responses to perceptual distortions.

Answer 20

a. returning to premorbid levels of function.

Question 21

An older adult with moderately severe dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the client’s family?

a. Label the bathroom door clearly.
b. Take the older adult to the bathroom hourly.
c. Place the older adult in disposable adult briefs.
d. Limit the intake of oral fluids to 1000 mL/day.

Answer 21

a. Label the bathroom door clearly.

Question 22

An older client diagnosed with severe, late-stage dementia no longer recognizes family members. The family asks how long it will be before this client recognizes them when they visit. What is the nurse’s best reply?

a. “Your family member will never again be able to identify you.”
b. “I think that is a question the health care provider should answer.”
c. “One never knows. Consciousness fluctuates in persons with dementia.”
d. “It is disappointing when someone you love no longer recognizes you.”

Answer 22

d. “It is disappointing when someone you love no longer recognizes you.”

Question 23

A client diagnosed with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members?

a. Wear large name tags.
b. Focus interaction on familiar topics.
c. Frequently repeat the reorientation strategies.
d. Place large clocks and calendars strategically.

Answer 23

b. Focus interaction on familiar topics.

Question 24

What is the priority need for a client diagnosed with severe, late-stage dementia?

a. Promotion of self-care activities
b. Meaningful verbal communication
c. Preventing the client from wandering
d. Maintenance of nutrition and hydration

Answer 24

d. Maintenance of nutrition and hydration

Question 25

An older adult is prescribed digoxin and hydrochlorothiazide daily as well as lorazepam as needed for anxiety. Over 2 days, the client developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the client’s change in mental status?

a. Drug actions and interactions
b. Benzodiazepine withdrawal
c. Hypotensive episodes
d. Renal failure

Answer 25

a. Drug actions and interactions

Question 26

A hospitalized client diagnosed with delirium misinterprets reality. A client diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? The clients will

a. remain safe in the environment.
b. participate actively in self-care.
c. communicate verbally.
d. acknowledge reality.

Answer 26

a. remain safe in the environment.

Question 27

An elderly client is admitted with delirium secondary to a urinary tract infection. The family asks whether the client will ever recover. What is the nurse’s best response?

a. “The health care provider is the best person to answer your question.”
b. “The confusion will probably get better as we treat the infection.”
c. “Unfortunately, delirium is a progressively disabling disorder.”
d. “I will be glad to contact the chaplain to talk with you.”

Answer 27

b. “The confusion will probably get better as we treat the infection.”

Question 28

An elderly adult presents with symptoms of delirium. The family reports, “Everything was fine until yesterday.” What is the most important assessment information for the nurse to gather?

a. A list of all medications the person currently takes
b. Whether the person has experienced any recent losses
c. Whether the person has ingested aged or fermented foods
d. The person’s recent personality characteristics and changes

Answer 28

a. A list of all medications the person currently takes

Question 29

A nurse gives anticipatory guidance to the family of a client diagnosed with mild early stage Alzheimer’s disease. Which problem common to that stage should the nurse address?

a. Violent outbursts
b. Emotional disinhibition
c. Communication deficits
d. Inability to feed or bathe self

Answer 29

c. Communication deficits

Question 30

A client diagnosed with moderate stage Alzheimer’s disease has a self-care deficit of dressing and grooming. Designate appropriate interventions to include in the client’s plan of care. (Select all that apply.)

a. Provide clothing with elastic and hook-and-loop closures.
b. Label clothing with the client’s name and name of the item.
c. Administer antianxiety medication before bathing and dressing.
d. Provide necessary items and direct the client to proceed independently.
e. If the client resists dressing, use distraction and try again after a short interval.

Answer 30

a. Provide clothing with elastic and hook-and-loop closures.
b. Label clothing with the client’s name and name of the item.
e. If the client resists dressing, use distraction and try again after a short interval.

Question 31

Which assessment findings would the nurse expect in a client experiencing delirium? (Select all that apply.)

a. Impaired level of consciousness
b. Disorientation to place, time
c. Wandering attention
d. Apathy
e. Agnosia

Answer 31

a. Impaired level of consciousness
b. Disorientation to place, time
c. Wandering attention

Question 32

Which nursing diagnoses are most applicable for a client diagnosed with severe late stage Alzheimer’s disease? (Select all that apply.)

a. Acute confusion
b. Anticipatory grieving
c. Urinary incontinence
d. Disturbed sleep pattern
e. Risk for caregiver role strain

Answer 32

c. Urinary incontinence
d. Disturbed sleep pattern
e. Risk for caregiver role strain