Deck 2 Module 23 Flashcards
The nurse is working with a group of parents of children with intellectual disabilities. Which should the nurse recommend to support environmental safety for these children?
Select all that apply.
A) Have parents maintain a regular schedule for activities.
B) Teach emotional safety.
C) Use medications to decrease agitation.
D) Provide aids to assist with orientation.
E) Turn the temperature down on the hot water heater.
B) Teach emotional safety.
E) Turn the temperature down on the hot water heater.
Rationale:
Turning the temperature down on the hot water heater will help to prevent accidental burns when bathing or washing dishes. Teaching emotional safety can decrease the risk of physical or sexual abuse. Using therapeutic measures to decrease agitation is recommended for clients with high risk for other-directed violence. Although a routine daily schedule and orientation aids will structure the client’s environment to promote optimal orientation, they will not necessarily improve environmental safety.
A client is admitted with signs and symptoms of early Alzheimer disease. What would be used to confirm this client’s diagnosis?
A) Abnormal CT scan findings of neuritic plaques and tangles in the brain
B) Client history and physical examination
C) Positive blood tests for beta-amyloid and tau proteins
D) Blood test for amyloid plaques and neurofibrillary tangles
B) Client history and physical examination
Rationale:
The diagnosis of Alzheimer disease is based on the client history and physical examination. There is currently is no one test or procedure that makes the diagnosis of Alzheimer disease. Changes in the brain with Alzheimer disease include neuritic plaques containing beta-amyloid protein and neurofibrillary tangles containing tau protein, but these changes are found at autopsy, not by a CT scan or blood test.
A nursing instructor is teaching a group of student nurses about the different theories of cognition. Which cognitive development theory proposes that all children progress through the same stages of development? A) Piaget B) Vygotsky C) Information-processing D) Erickson
A) Piaget
Rationale:
Piaget’s cognitive development theory proposes that all children progress through the same stages of development. Vygotsky’s theory, on the other hand, discards the idea that all children progress through the same stages of development. Instead, Vygotsky theorized that skill development is influenced by the child’s environment and culture. The information-processing theory views the mind as a computer that is always changing and evolving and takes in information, operates on it, and converts it to answers. Erickson’s theory is not a cognitive development theory, but rather is a behavioral development theory.
A nurse is caring for an older adult who displays symptoms of cognitive decline. Which is true regarding the aging process and cognition?
Select all that apply.
A) Generally, older adults’ short-term memory changes significantly.
B) Generally, many older adults have increased difficulty finding and rapidly listing words.
C) The ability to use and understand word combinations declines steadily with age.
D) The ability to acquire practical information declines steadily with age.
E) The ability to engage in abstract thought declines slightly.
B) Generally, many older adults have increased difficulty finding and rapidly listing words.
E) The ability to engage in abstract thought declines slightly.
Rationale:
As adults age, many have increased difficulty finding and rapidly listing words. Also, the ability to engage in abstract thought declines slightly. However, in general, older adults’ short-term memory remains intact and the ability to use and understand word combinations remains intact as well. Most older adults are able to acquire practical information until their death.
A student nurse is learning about the physiology of the nervous system and its relationship to cognition. What structure plays a role in memory formation? A) Neuron B) Hippocampus C) Cerebrum D) Neurotransmitter
B) Hippocampus
Rationale:
The structure that plays a role in memory is the hippocampus, located in the limbic system of the brain. A neuron carries and processes information within the nervous system. The cerebrum is the largest region of the brain. A neurotransmitter is a chemical messenger within the nervous system.
The nurse is preparing an educational program for the family of a client with Alzheimer disease who is ready for discharge. Which will the nurse focus on to reduce the client’s risk for injury?
Select all that apply.
A) Have all objects in the room be the same color.
B) Check shoes for fit and support.
C) Be aware that client in the early stages usually have few problems with unfamiliar places.
D) Keep all familiar objects in the home.
E) Remove throw rugs and electrical cords.
B) Check shoes for fit and support.
E) Remove throw rugs and electrical cords.
Rationale:
Clients with chronic confusion, as often seen with dementia associated with Alzheimer disease, are at increased risk for falls. Shoes should fit and be supportive. Simplifying the home environment while keeping familiar furniture in the same space will assist the client to cope better safely. Clutter should be removed to reduce anxiety and suspicions, and to promote safety. The concept of “pop up”–using a contrast in colors to assist the client in finding an object in a room–should be explained to caregivers. For example, a white toilet in a blue room is easier to distinguish than a white toilet in a white room. Even in early stages of dementia, clients have difficulty dealing with unfamiliar places.
The nurse is planning care for a client who is experiencing Stage 1 Alzheimer disease. Which intervention will promote a therapeutic environment for a client with acute confusion?
A) Background noise like music will keep this client calm.
B) Dim the lights during waking hours.
C) Schedule meals at the same time each day.
D) Pain medications will enhance the therapeutic environment.
C) Schedule meals at the same time each day.
Rationale:
The client with dementia benefits from a routine schedule of activities, including meal times. The client typically is better oriented when it is quiet. Pain medications should be administered if pain is present, but these medications will not enhance the therapeutic environment. It is important keep the room lit during waking hours; the lights should not be dimmed during this time.
The nurse includes information regarding long-term care placement in the discharge materials for the family of a client newly diagnosed with Alzheimer disease. Which is the rationale for providing this information to the family at this time?
A) It often takes 6 to12 months for an individual with Alzheimer disease to establish a successful transfer to a facility, and this will allow adequate time.
B) It’s better to address the issue of placement now instead of later.
C) Early introduction to long-term options will allow the client and family time to make a more informed decision.
D) Long-term care placement is inevitable with this diagnosis.
C) Early introduction to long-term options will allow the client and family time to make a more informed decision.
Rationale:
Although placement in a long-term care facility is not going to be the fate of all individuals with Alzheimer disease, it is a common one. Providing the information early in the disease process allows the family to make an informed choice. Nurses will need to provide reinforced education and referrals throughout the disease process, not just during the initial hospitalization. There is no plan to transfer the client at this time; adjustment would occur after the transfer.
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.
A) Damage to the limbic system results in speech decline and slowed movements.
B) Familial Alzheimer disease (FAD) is also called delayed-onset Alzheimer disease.
C) Sporadic Alzheimer disease usually manifests before age 65.
D) Sporadic Alzheimer disease is more common than familial Alzheimer disease.
E) In Alzheimer disease, neuronal cells die in a characteristic order.
D) Sporadic Alzheimer disease is more common than familial Alzheimer disease.
E) In Alzheimer disease, neuronal cells die in a characteristic order.
Rationale:
) 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.
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? A) Stage 3 B) Stage 4 C) Stage 5 D) Stage 6
C) Stage 5
Rationale:
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).
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? A) Delirium B) Sundown syndrome C) Anxiety D) Psychosis
B) Sundown syndrome
Rationale:
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.
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?
A) Making sure the parents can set up the treatments for their child
B) Encouraging the family to remain at the bedside with the client
C) Making sure the child comes back for the follow-up appointment
D) Providing written instructions before discharge
B) Encouraging the family to remain at the bedside with the client
Rationale:
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.
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.
A) Reorient the client to time and place as much as possible.
B) Encourage the family remain at the bedside as much as possible.
C) Explain that high fevers can cause delirium.
D) Reassure that the confusion will not last very long.
E) Teach the family how to care for the child upon discharge.
B) Encourage the family remain at the bedside as much as possible.
C) Explain that high fevers can cause delirium.
Rationale:
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.
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?
A) It consists of five parts and is a lengthy test.
B) It measures the severity of the client’s delirium.
C) It is also effective in screening for depression.
D) It is effective in screening for cognitive impairment and reversible confusion.
D) It is effective in screening for cognitive impairment and reversible confusion.
Rationale:
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.
The nurse is helping the family of an adolescent understand why their child has been diagnosed with schizophrenia. Which risk factor in the client’s history supports the current diagnosis? A) Association with psychotic clients B) Smoking C) Genetic predisposition D) Allergy to shellfish
C) Genetic predisposition
Rationale:
Studies have shown that there is a genetic predisposition to the development of schizophrenia. Smoking, allergies to foods, and association with others have not been shown to cause schizophrenia.
