Deck 3 - Module 23

Question 1

The family of an older adult client is concerned about the changes in the client's behavior. The client used to be a wonderful cook but now cannot even remember how to use a blender. For which causes of impaired cognitive function should the nurse assess the client? Select all that apply.
A) Obesity
B) Nutritional deficiencies
C) Medication reactions
D) Stroke 
E) Snoring

Answer 1

B) Nutritional deficiencies
C) Medication reactions
D) Stroke

Rationale:

Any change or deviation from normal in an individual’s cognitive function should be evaluated. Dementia can be caused or exacerbated by other conditions and variables, including metabolic problems, nutritional deficiencies, infections, poisoning, medications, and any conditions that compromise oxygenation and perfusion. Snoring and obesity are not conditions noted to result in impaired cognitive functioning.

Question 2

The nurse is assessing an older adult client and observes that the client is having several cognitive problems, including memory and attention deficits and fluctuating levels of orientation. The nurse confirms with the family that the client's symptoms developed over a several-year period. The client's symptoms are commonly observed with which condition?
A) Depression
B) Dementia
C) Intellectual disability
D) Delirium

Answer 2

B) Dementia

Rationale:

Dementia is a chronic progressive disorder characterized by memory impairments that develop slowly over a longer period of time. Depression is a mood disorder that is characterized by a dysphoric mood or loss of interest in usual activities. Delirium is an acute, abrupt-onset condition characterized by prominent disorientation, impaired attention, and memory deficits. Intellectual disability is defined as significant limitation in intellectual functioning and adaptive behaviors that occurs before the age of 18.

Question 3

An older adult client comes into the clinic for a pneumonia vaccine. During the client interview, the client reports occasionally having difficulty remembering some words, but denies any other concerns. The client is alert and oriented to time, person, and place, and most responses are appropriate. How should the nurse describe this client’s cognitive changes?
A) Memory impairment that may be related to cerebral ischemia
B) Normal signs of aging
C) Indicators of depression in the elderly
D) Early symptoms of dementia

Answer 3

B) Normal signs of aging

Rationale:

Older adults typically have more difficulty with cognitive functions, such as word retrieval and episodic memory; however, the impact on overall cognitive function should be minimal. The changes described for this client are normal signs of aging and not symptoms of dementia, depression, or ischemia. Dementia may present with additional symptoms of memory loss related to orientation and completing day-to-day tasks. Depression would show signs of flat affect, or withdrawal, and ischemia may show additional neurologic deficits.

Question 4

While assessing the cognitive status of a school-age child, the nurse notes that the child was unable to perform basic mathematical problems and unable to name several former presidents of the United States. Prior to considering the possibility that this client has cognitive issues, which factor should be reviewed?
A) The child’s age and developmental status
B) The child’s living arrangements with separated parents
C) The child’s currency of vaccinations
D) The child’s hobbies performed in leisure time

Answer 4

A) The child’s age and developmental status

Rationale:

The nurse must consider a pediatric client’s level of cognitive development before asking questions that involve calculation, judgment, or abstract thought. Even children with normal cognition will be unable to respond appropriately if they have not yet achieved the level of development necessary for these activities. The child’s home environment, currency of vaccinations, and hobbies will not explain why the child is unable to correctly respond to questions having to do with complicated math or history.

Question 5

A client with dementia is prescribed donepezil (Aricept). Which should the nurse consider when teaching this client about the medication?
A) Donepezil shortens the early stages of Alzheimer disease.
B) Donepezil is an acetylcholinesterase inhibitor that has a modest effect in slowing the progression of Alzheimer disease.
C) Donepezil is an anticholinergic and has been known to eradicate some of the symptoms associated with Alzheimer disease.
D) Donepezil should be taken on an empty stomach.

Answer 5

B) Donepezil is an acetylcholinesterase inhibitor that has a modest effect in slowing the progression of Alzheimer disease.

Rationale:

Acetylcholinesterase inhibitors reduce acetylcholine breakdown and have a modest effect in slowing an individual’s rate of cognitive decline in Alzheimer disease. Symptoms are not eradicated, but progression is slowed. These medications should be taken on a full stomach, and antiemetic medications may also be needed.

Question 6

Which cognitive development theory proposes that all children progress through the same stages of development?
A) Piaget
B) Vygotsky
C) Information-processing
D) Erickson

Answer 6

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.

Question 7

Which is true regarding the aging process and cognition?
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.

Answer 7

B) Generally, many older adults have increased difficulty finding and rapidly listing words.

Rationale:

Older adults typically have more difficulty with cognitive functions, such as word retrieval and episodic memory. 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.

Question 8

The nurse is caring for a client with perceptual disturbances who is becoming agitated. Which action should the nurse take first?
A) Distract client by taking into the dayroom to watch television with other clients.
B) Administer medications to sedate client before violent behaviors occur.
C) Request client to go back to room and dim lights.
D) Do nothing, as this is a normal manifestation of disturbed cognition.

Answer 8

C) Request client to go back to room and dim lights.

Rationale:

The nurse who observes a client demonstrating visual disturbances and/or psychotic behaviors should intervene by decreasing the environmental stimulus. If overstimulated, the client with visual disturbances or psychosis may display agitation. The use of physical and pharmacologic restraints should be avoided. Taking the client into the dayroom to watch television with others may overstimulate the client, further increasing agitation, which may increase risk of violence toward others.

Question 9

The nurse walks into the client room, and the client is confused and disoriented. Ten minutes prior, the client was oriented to person, place, and time and was not confused. Which nursing action is priority?
A) Position client in supine position
B) Assess vital signs and pulse oxygenation
C) Ambulate client to encourage lung expansion
D) Obtain urine for urinalysis

Answer 9

B) Assess vital signs and pulse oxygenation

Rationale:

Decreased O2 reaching the brain may lead to cognitive impairment, coma, and death. A client demonstrating a rapid onset of confusion and disorientation will need to have vital signs, pulse oximetry, and airway assessed for signs of impaired perfusion. Ambulating a client demonstrating these symptoms would be premature and could cause additional harm if there is impaired oxygen perfusion. Although urinary tract infections may cause acute mental status changes, the priority action would not be to obtain urine for a urinalysis.

Question 10

A 7-year-old child presents to the primary care office for a routine physical. Which question should the nurse include during the interview to identify the need for education related to preventing potential cognitive disorders?
A) “Do you wear a helmet when you ride a bicycle or skateboard?”
B) “How many times per day do you brush your teeth?”
C) “How are your grades in school?”
D) “How many hours per day do you watch television?”

Answer 10

A) “Do you wear a helmet when you ride a bicycle or skateboard?”

Rationale:

Nurses accomplish prevention and protective measures through teaching and providing anticipatory guidance. An example of an independent intervention is ensuring that children wear their bicycle helmets to aid in prevention of head trauma that could lead to cognitive abnormalities. The other options are important to assess but are irrelevant to impaired cognition.

Question 11

The spouse of a client with Alzheimer disease does not understand why the client developed the disorder because no one else in the family has the health problem. Which response by the nurse is appropriate?
A) “Alzheimer disease develops because of smoking and alcohol intake.”
B) “Someone in your family must not have been correctly diagnosed with the disorder.”
C) “Alzheimer disease does not have the same course in every individual.”
D) “There are genetic and environmental factors in the development of Alzheimer disease.”

Answer 11

D) “There are genetic and environmental factors in the development of Alzheimer disease.”

Rationale:

Researchers are not sure why most cases of Alzheimer disease (AD) arise, although a variety of genetic and environmental factors appear to be involved. Alzheimer disease is not directly linked to smoking and alcohol intake. It is inappropriate to assume that other family members had the disorder but were misdiagnosed. Alzheimer disease has a predictable course with distinct phases or stages.

Question 12

An adult child brings a parent in to be evaluated and is told the client has Alzheimer disease. The adult child asks the nurse if he is also at risk for the disease. Which risk factors should the nurse include when responding? Select all that apply.
A) Genetic predisposition
B) Age
C) History of hypertension
D) Hearing deficits
E) Gender

Answer 12

A) Genetic predisposition
B) Age
C) History of hypertension
E) Gender

Rationale:

The most prominent risk factor for Alzheimer disease is advancing age. Individuals with a family history of AD are more likely to develop the disease, even in the absence of known genetic factors that predict or increase the risk of the disease. Research has identified risk factors of AD to include cardiovascular risks such as diabetes, mid-life obesity, mid-life hypertension, and hyperlipidemia. AD is almost three times more common in women than men. There is no indication that hearing deficits play a role in the development of Alzheimer disease.

Question 13

A client diagnosed with Alzheimer disease becomes agitated during an activity involving simultaneous music playing and a craft project. The client starts shouting, “No! No! No!” and runs from the room. Which action by the nurse is the most appropriate?
A) Administer a prn anti-anxiety medication.
B) Restrict participation in any group activities.
C) Call security and prepare physical restraints.
D) Reassure the client and then redirect to a quiet area.

Answer 13

D) Reassure the client and then redirect to a quiet area.

Rationale:

Environmental stimuli should be kept at a minimum for clients with dementia. A quiet environment will prevent sensory overload. Once the client is less agitated, the client can be directed to a less stimulating activity. Use of physical and pharmacologic restraints should be avoided.

Question 14

A nurse is preparing an educational program for clients in a long-term care facility regarding protective factors for Alzheimer disease (AD). Which information should the nurse include? Select all that apply.
A) Becoming involved in activities such as reading that keep the mind active
B) Incorporate a high-calorie, high-carbohydrate diet to decrease formation of amyloid plaques
C) Remain socially active
D) Including modest exercise into daily regimen
E) Begin drinking a glass of wine each night before bed

Answer 14

A) Becoming involved in activities such as reading that keep the mind active
C) Remain socially active
D) Including modest exercise into daily regimen

Rationale:

Evidence demonstrates that cognitive activities such as reading, completing puzzles, and learning new information or tasks build cognitive resilience and protect against cognitive decline. There is some evidence to suggest that the heart-healthy diets that include antioxidant- and polyphenol-rich foods such as tea, cocoa, grapes, and colorful fruits and vegetables may interrupt formation of amyloid plaques and prevent AD. Social engagement may improve cognitive function and have some protective effects against AD. Modest levels of exercise have been demonstrated to improve cognitive function. Moderate alcohol consumption may be protective against AD. However, evidence is insufficient to suggest that individuals who do not already drink should start drinking.

Question 15

The nurse is planning care for a client with stage 1 Alzheimer disease. Which are the priority nursing diagnoses for the client and family?
A) Impaired Memory and Caregiver Role Strain
B) Hopelessness and Functional Family Processes
C) Knowledge Deficit and Ineffective Coping
D) Pseudohostility and Ineffective Coping

Answer 15

A) Impaired Memory and Caregiver Role Strain

Rationale:

Appropriate nursing diagnoses may depend on the stage of Alzheimer disease (AD). Impaired Memory is an appropriate nursing diagnosis in stage 1 AD. Caregiver Role Strain is appropriate for any stage of AD. Functional Family Processes and Ineffective Coping are not diagnoses related to cognitive behavioral assessment. Pseudohostility is not a nursing diagnosis.

Question 16

The nurse is planning care to address safety needs for an older adult client who has recently been diagnosed with early Alzheimer disease. Which interventions are appropriate to address safety needs? Select all that apply.
A) Use of a restraint belt at night to prevent wandering behaviors
B) Check shoes for fit and support.
C) Contact the department of motor vehicles to have the client’s license suspended.
D) Keep all familiar objects in the home.
E) Remove throw rugs and electrical cords.

Answer 16

B) Check shoes for fit and support.
E) Remove throw rugs and electrical cords.

Rationale:

All older clients, including those with Alzheimer disease (AD), are at increased risk for injuries such as falls. Shoes should fit and be supportive. Simplifying the home environment while keeping familiar furniture in the same space will reduce confusion and promote safety. Rugs and cords should be removed to prevent falls. The use of physical and pharmacologic restraints should be avoided. In early stages of dementia, clients with Alzheimer disease may continue to drive.

Question 17

The nurse is planning care for a client who is experiencing stage 1 Alzheimer disease. Which intervention will best promote cognitive function?
A) Ensure there is background music or sound from the television.
B) Dim the lights during waking hours.
C) Maintain a daily routine.
D) Keep social interaction to a minimum.

Answer 17

C) Maintain a daily routine.

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. It is important keep the room lit during waking hours; the lights should not be dimmed during this time.

Question 18

The nurse is educating the family and client, who was recently diagnosed with Alzheimer disease (AD), regarding long-term care placement. Which is the rationale for providing this information to the family at this time?
A) It often takes 6 to 12 months for an individual with AD 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.

Answer 18

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.

Question 19

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.
A) Resolving grief over the diagnosis
B) Deciding on the desired treatment and selecting a healthcare proxy; sharing the treatment decision with the healthcare proxy
C) Beginning cognitive-enhancing medication, such as Aricept
D) Setting up a protective physical environment—such as removing throw rugs
E) Making provisions for assistance with activities of daily living (ADLs)

Answer 19

A) Resolving grief over the diagnosis
B) Deciding on the desired treatment and selecting a healthcare proxy; sharing the treatment decision with the healthcare proxy
C) Beginning cognitive-enhancing medication, such as Aricept
D) Setting up a protective physical environment—such as removing throw rugs

Rationale:

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. Clients in stage 1 of Alzheimer disease continue to be proficient with ADLs and do not require assistance.

Question 20

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?
A) Improve language deficits
B) Improve muscle tone
C) Ability to perform activities of daily living
D) Improve access to community organizations

Answer 20

C) Ability to perform activities of daily living

Rationale:

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 21

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.
A) Glutamatergic inhibitors are the most common class of drugs for treating Alzheimer disease.
B) Alzheimer disease accounts for about 80% of all dementias.
C) Chronic inflammation of the brain may be a cause of the disease.
D) Depression and aggressive behavior are common with the disease.
E) Memory difficulties are an early symptom of the disease.

Answer 21

B) Alzheimer disease accounts for about 80% of all dementias.
C) Chronic inflammation of the brain may be a cause of the disease.
D) Depression and aggressive behavior are common with the disease.
E) Memory difficulties are an early symptom of the disease.

Rationale:

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 80% of all dementias. The acetylcholinesterase inhibitors, not the glutamatergic inhibitors, are the most widely used class of drugs for treating the disease.

Question 22

The nurse is reviewing pharmacologic treatments with a caregiver of an individual with Alzheimer disease. Which statement indicates that teaching has been effective?
A) “There are effective drugs, but they cannot be used over a long period.”
B) “There aren’t any drugs that are effective in treating this disease.”
C) “The earlier the drugs are started, the greater the likelihood they will have benefits.”
D) “There are drugs that can control symptoms for many years.”

Answer 22

C) “The earlier the drugs are started, the greater the likelihood they will have benefits.”

Rationale:

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.

Question 23

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?
A) Encouraging the caregiver to obtain rest and eat a healthy diet
B) Providing the client a list of daily activities to complete
C) Making arrangements for the client to visit the local senior citizen center in the afternoon
D) Finding placement in a long-term care facility

Answer 23

A) Encouraging the caregiver to obtain rest and eat a healthy diet

Rationale:

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 obtain the sleep and nutrition necessary to preserve personal health. 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 24

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?
A) Temporal lobe
B) Limbic system
C) Frontal lobe
D) Occipital lobe

Answer 24

A) Temporal lobe

Rationale:

Damage to the client’s temporal lobe manifests as impaired memory, difficulty learning new things, and receptive aphasia. Damage to the limbic system manifests as loss of memory, fluctuating emotions, depression, and difficulty learning new information. Damage to the frontal lobe manifests as problems with intentional movement, fluctuating emotions, and loss of the ability to walk. Frontal lobe damage also 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 25

Which is true regarding the pathophysiology and etiology of Alzheimer disease? Select all that apply.
A) Damage to the limbic system results in speech decline and slowed movements.
B) Familial Alzheimer disease (eFAD) 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.

Answer 25

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 (eFAD) 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 26

A nurse is assessing a client diagnosed with Alzheimer disease (AD) in which the family reports that the client recently lost the ability to live independently and is unable to perform certain activities of daily living (ADLs) such as selecting appropriate clothing or preparing meals. The family's report indicates that the client has progressed to which stage of AD?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4

Answer 26

B) Stage 2

Rationale:

This client is in stage 2 (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 1 (mild cognitive impairment) is able to maintain living independently, but the client’s memory lapses are apparent to others. In stage 3 (severe AD), individuals become unable to perform even basic activities of daily living (ADLs). AD is described in terms of three stages: stage 1 (early), stage 2 (moderate), and stage 3 (severe).

Question 27

The nurse is educating a client who is diagnosed with stage 1 Alzheimer disease (AD) and the client’s spouse. Which suggestion best promotes maintaining functional ability at this stage?
A) Obtain round-the-clock care at home
B) Prepare liquid nutrition
C) Assist client with ADLs
D) Begin making “to-do” lists and use of a calendar

Answer 27

D) Begin making “to-do” lists and use of a calendar

Rationale:

Use of cuing devices such as to-do lists, calendars, written schedules, and verbal reminders can aid in maintaining client’s highest level of functioning. The other options are interventions for a client diagnosed with stage 3 AD.

Question 28

A client presents with signs and symptoms of early Alzheimer disease. What would be used to confirm this client’s diagnosis?
A) Abnormal CT scan findings of 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

Answer 28

B) Client history and physical examination

Rationale:

The diagnosis of Alzheimer disease is based on the client history and physical examination. There is currently no one test or procedure that makes the diagnosis of Alzheimer disease. As AD progresses and more neurons die, two characteristic abnormalities develop in the brains of affected individuals. The first is thick protein clots called neurofibrillary tangles, and the second is insoluble deposits known as amyloid plaques, but these changes are found at autopsy, not by a CT scan or blood test.

Question 29

The nurse is teaching the family of a client who has just been diagnosed with dementia. The family asks if there are treatments available that will cure the client. What would be the nurse’s best response to the family?
A) “There are no treatments that will cure dementia at this time.”
B) “Treatments to cure dementia include the use of vitamin E.”
C) “Treatments to cure dementia involve hormone replacement therapy.”
D) “There are no treatments that can slow the progression of the disease.”

Answer 29

A) “There are no treatments that will cure dementia at this time.”

Rationale:

Currently no treatment has been found to reverse or stop the pathologic process in progressive dementia. Studies on the use of dietary supplements such as antioxidant vitamins, gingko biloba, resveratrol, omega-3 fatty acids, and medical food such as tramiprosate (Vivimind) and caprylic acid for the management of AD are inconclusive at best and associated with risks such as interaction with other drugs and toxicity. There are two classes of medications used to slow the progression of the disease.

Question 30

Damage to which region of the brain may result in loss of recent memory?
A) Neuron
B) Hippocampus
C) Cerebrum
D) Neurotransmitter

Answer 30

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.

Question 31

An older adult client complains of periods of confusion and forgetfulness, but reports clear thought process at most times of the day. Which is the appropriate response from the nurse?
A) “Are you having trouble hearing?”
B) “You probably have nothing to worry about. It’s most likely stress-related.”
C) “Everybody has a few problems with memory as they get older.”
D) “You should probably have an MRI of your brain.”

Answer 31

A) “Are you having trouble hearing?”

Rationale:

People who cannot hear or see well often appear confused. The nurse should assess whether the client is having difficulty with these prior to moving on in the assessment process. Determine the degree of impairment and explore the possibility that this hearing impairment may be contributing to the client’s confusion. A nurse should never discount the client’s concerns, and memory loss with confusion and forgetfulness is not part of the normal aging process. The nurse needs to explore further before an expensive diagnostic study is considered. It would be beyond the scope of practice for the nurse to recommend this testing.

Question 32

An older adult client with no history of cognitive impairment is suddenly showing signs of increased confusion and possible delirium. Which health problem should the nurse suspect is causing this client's confusion?
A) Cataracts
B) Hypertension
C) Urinary tract infection
D) Lower back strain

Answer 32

C) Urinary tract infection

Rationale:

Delirium is often the most prominent manifestation of conditions such as dehydration, respiratory tract infections, urinary tract infections, and urinary retention, and adverse drug events may occur in the absence of symptoms such as fever or discomfort. Hypertension, lower back strain, and cataracts are not conditions that are known to cause signs of confusion in older adults.

Question 33

The nurse is caring for a client who becomes confused and agitated every evening. Medical reasons for the change in mental status have been ruled out. The nurse correctly communicates to the other healthcare team members that the client is experiencing which phenomenon?
A) Delirium
B) Sundowning
C) Aphasia
D) Chronic psychosis

Answer 33

B) Sundowning

Rationale:

Sundowning is understood as confusion that intensifies in the evening or at bedtime. 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. Aphasia is the inability to use or understand language. Psychosis is a mental disorder, and this client is not exhibiting signs of psychosis.

Question 34

The family of an older adult client is informed that the client has delirium. Which statement indicates that the family understands the diagnosis?
A) “It’s sad that dad is getting dementia.”
B) “The changes in his behavior came on so quickly, which may be the result of an underlying medical condition.”
C) “Our father is going to need long-term psychiatric care.”
D) “Confusion is normal in older adults, and it goes away on its own.”

Answer 34

B) “The changes in his behavior came on so quickly, which may be the result of an underlying medical condition.”

Rationale:

Delirium is characterized by a rapid and abrupt onset of symptoms and caused by an underlying medical condition. Once the medical condition is treated, the delirium resolves. 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 35

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?
A) Ambien (zolpidem), a hypnotic/sedative, taken at bedtime for sleep
B) The client’s age
C) The death of the client’s husband last month
D) History of cardiac disease

Answer 35

A) Ambien (zolpidem), a hypnotic/sedative, taken at bedtime for sleep

Rationale:

Certain medications, such as hypnotics/sedatives, anxiolytics, antidepressants, anti-Parkinson drugs, anticonvulsants, or antispasmodics, also increase symptoms of delirium. 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 36

A 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 perform all 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

Answer 36

B) Encouraging the family to remain at the bedside with the client

Rationale:

Besides the prevention and management of the underlying medical condition, the presence of parents and family members has been found to reduce the incidence of delirium. All of the other interventions are important for the discharge planning of this client.

Question 37

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 deceased for 5 years. Prior to the hospitalization, the client was oriented to person, place, time, and reality. Which nursing diagnoses would be appropriate for this client? Select all that apply.
A) Risk for Autonomic Dysreflexia
B) Anxiety
C) Acute Confusion
D) Risk for Injury
E) Ineffective Coping

Answer 37

C) Acute Confusion
D) Risk for Injury

Rationale:

The client is experiencing acute confusion and is also at risk for injury 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 38

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?
A) “It is important to provide education for family members as needed.”
B) “Sensory deprivation and overstimulation can worsen the symptoms the client exhibits.”
C) “Decreasing all stimulation in the client’s room is essential.”
D) “The family should involve the client in all conversations and interactions involving care.”

Answer 38

B) “Sensory deprivation and overstimulation can worsen the symptoms the client exhibits.”

Rationale:

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 39

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?
A) “The cause of delirium is always unknown.”
B) “Dementia develops suddenly.”
C) “Delirium is a serious but common occurrence in older adult clients who are hospitalized.”
D) “Delirium is often confused with depression in older adult clients.”

Answer 39

C) “Delirium is a serious but common occurrence in older adult clients who are hospitalized.”

Rationale:

Hospitalized clients are much more likely to experience delirium because of the presence of predisposing illnesses, exposure to multiple medical interventions that may contribute to cognitive changes, and being in an environment that is unfamiliar, stimulating, and not conducive to maintaining normal diurnal rhythms. Delirium is an acute rapid-onset condition with an etiology that can usually 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 40

The nurse identifies a nursing diagnosis of Risk for Injury for a client who is disoriented. Which is an expected outcome for this client’s care?
A) The client does not sustain injuries during wanderings.
B) The client remains continent of bowel and urine.
C) The client receives culturally appropriate care.
D) The client sleeps through the night and stays awake most of the day.

Answer 40

A) The client does not sustain injuries during wanderings.

Rationale:

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 41

The nurse is caring for a school-age client who was admitted with pneumonia and high fever. The parents are very upset because the child is now unable to recognize them. Which statements should the nurse include while educating the parents on their child’s symptoms? 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.

Answer 41

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 any febrile illness may cause symptoms of delirium and that this symptom will abate when the temperature returns to normal. The presence of parents and family members has been found to reduce the incidence of delirium as well as decrease family stress. 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 42

Which is true regarding the Confusion Assessment Method (CAM)?
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.

Answer 42

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.

Question 43

A nurse manager is educating a group of staff nurses on recognizing the differences between confusion and delirium. Which statements should be included in the teaching? Select all that apply.
A) “Delirium is seen only in older adults.”
B) “Delirium is a reversible condition while dementia is not.”
C) “Older adults are at higher risk for developing delirium.”
D) “Younger adult females are at higher risk for developing delirium.”
E) “Adolescents are more prone to developing delirium than young children.”

Answer 43

B) “Delirium is a reversible condition while dementia is not.”
C) “Older adults are at higher risk for developing delirium.”

Rationale:

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 adults are at higher risk for developing delirium, not younger adult females. Also, young children are at greater risk for developing delirium than adolescents because children’s bodies are less equipped to cope with insults such as fever, infection, and toxin exposure.

Question 44

The nurse is caring for a client with schizophrenia whose symptoms of psychosis have resolved. The client’s family complains that the client’s hygiene remains poor and he lacks motivation and initiative. Which conclusion by the nurse is most appropriate?
A) The client is experiencing negative symptoms.
B) The client is experiencing disordered thinking.
C) The client was misdiagnosed.
D) The client is most likely hearing voices.

Answer 44

A) The client is experiencing negative symptoms.

Rationale:

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 45

The nurse is educating an adolescent client diagnosed with schizophrenia on predisposing risk factors. Which significant risk factor should the nurse include in the teaching?
A) Summer birthdate
B) Parents recently divorced
C) Positive family history
D) Lives in rural setting

Answer 45

C) Positive family history

Rationale:

The most significant risk factor for schizophrenia is a positive family history. There is evidence that individuals born in late winter may be at greater risk of developing the illness, possibly due to exposure to infection. Although stress can trigger the illness in certain susceptible individuals, it is not a risk factor itself. Living in a rural area is not a risk factor for schizophrenia.

Question 46

The nurse is teaching techniques to improve communication skills to a family with a member with schizophrenia. Which techniques should be included? Select all that apply.
A) Use active listening.
B) Making positive, specific requests for change.
C) Use “I” language to express feelings.
D) Encourage client to communicate with only family.
E) Use “you” statements to point out negative behavior.

Answer 46

A) Use active listening.
B) Making positive, specific requests for change.
C) Use “I” language to express feelings.

Rationale:

Increasing communication in a safe setting with family and friends helps to stimulate both self-confidence and the fostering of important relationships. Use “I” language to express positive feelings (e.g., “I am happy when you decide to sit down for dinner with us”). Engage in active listening (e.g., asking questions and nodding in agreement when another person speaks). Make positive, specific requests for change that are linked to emotions (e.g., “I would really like it if you could play a game with us tonight”). Express negative feelings with “I” rather than “you” language (e.g., saying “I’m worried that you may not be getting enough sleep” instead of “You never get enough sleep at night”).

Question 47

The nurse is caring for a client who is experiencing auditory hallucinations. Which is the priority nursing diagnosis for this client?
A) Disturbed Thought Processes
B) Individual Ineffective Coping
C) Impaired Verbal Communication
D) Risk for Violence, Self-Directed or Other-Directed

Answer 47

D) Risk for Violence, Self-Directed or Other-Directed

Rationale:

Maintaining a safe environment is the priority diagnosis. When hallucinating or interpreting others’ actions and statements from the standpoint of delusions, the client may believe herself to be in danger, regardless of whether there is a factual basis for her fear. Under such circumstances, both the client and perceived aggressors may be at risk for injury. Although the client has impaired thought processes, this is not the priority diagnosis at this time. Individual Ineffective Coping and Impaired Verbal Communication are also correct diagnoses, but the key word here is “priority,” and this client has a potential or risk for harm to self or others.

Question 48

The nurse is providing education related to improving family dynamics for the family of an adolescent diagnosed with schizophrenia. Which topics should be included in the teaching? Select all that apply.
A) Establish boundaries
B) Identify coping mechanisms
C) Discuss childhood memories
D) Prevent future episodes
E) Improve communication

Answer 48

A) Establish boundaries
B) Identify coping mechanisms
E) Improve communication

Rationale:

The goal is to help clients and families cope, improve their communication and interpersonal skills, establish boundaries, and moderate family cohesion and flexibility. The family may not be able to prevent future psychologic episodes. Discussing childhood memories is irrelevant to treatment.

Question 49

The healthcare provider prescribes aripiprazole (Abilify) for the client with schizophrenia. Which is the priority outcome for the client?
A) The client will report a decrease in auditory hallucinations.
B) The client will report symptoms of restlessness.
C) The client will consume adequate fluids and a high-fiber diet.
D) The client will adhere to the medication regime.

Answer 49

D) The client will adhere to the medication regime.

Rationale:

Medication compliance is a priority for clients with schizophrenia. Relapse of symptoms will occur without the medications. The symptom of restlessness is known as akathisia. This would be important to report, but it is not the priority outcome. Adequate fluids and fiber will decrease the side effect of constipation, but this is not the priority outcome. A decrease in auditory hallucinations is an expected effect of aripiprazole (Abilify), but this is not the priority outcome.

Question 50

The nurse is running a group therapy session for clients diagnosed with schizophrenia. Which interventions address the cognitive deficits associated with this disorder?
A) Have clients wear name tags.
B) Provide a highly stimulating environment.
C) Encourage open-ended activities.
D) Use humor.

Answer 50

A) Have clients wear name tags.

Rationale:

Facial agnosia is a cognitive alteration frequently associated with schizophrenia. Name tags assist clients to remember other group members’ names and may foster social interaction. Decreased stimuli would address deficits in focus and attention. Structured activities and cues are required to address lack of spontaneity in speech. Individuals with schizophrenia may have concrete thinking and may not respond well to humor.

Question 51

The client is receiving risperidone (Risperdal) for the treatment of schizophrenia. Which client statement indicates the medication is effectively treating the positive symptoms of schizophrenia?
A) “I promise not to skip breakfast anymore.”
B) “I am not hearing the voices anymore.”
C) “I will start going to group therapy.”
D) “I feel better and I am ready to go home.”

Answer 51

B) “I am not hearing the voices anymore.”

Rationale:

Among the therapeutic effects of risperidone (Risperdal) is the remission of a range of psychotic symptoms that include delusions, paranoia, auditory hallucinations, and irrational behavior. A client stating he feels better and is ready to go home, stating he will go to group therapy, or stating he will not skip breakfast does not indicate the remission of any psychotic symptoms.

Question 52

The nurse is caring for the client prescribed thorazine. Which assessment findings alert the nurse to the possibility that the client has developed tardive dyskinesia? Select all that apply.
A) Wormlike motions of the tongue
B) Lip smacking
C) Unusual facial movements
D) Muscle spasms of the neck
E) Shuffling gait

Answer 52

A) Wormlike motions of the tongue
B) Lip smacking
C) Unusual facial movements

Rationale:

Tardive dyskinesia is characterized by unusual tongue and face movements such as lip smacking and wormlike motions of the tongue. Severe muscle spasms of the back, neck, and tongue are known as acute dystonia, not tardive dyskinesia.

Question 53

An adolescent client is admitted to the hospital for the treatment of schizophrenia. The client’s mother is confused and wants to know what she did to cause this to occur. Which responses by the nurse are appropriate? Select all that apply.
A) “Schizophrenia is a biological brain disorder.”
B) “Research indicates that schizophrenia is a genetic disorder.”
C) “Research indicates that a very stressful environment causes schizophrenia.”
D) “Schizophrenia is due to too much dopamine in certain parts of the brain.”
E) “Schizophrenia is linked to drinking alcohol during pregnancy.”

Answer 53

A) “Schizophrenia is a biological brain disorder.”
B) “Research indicates that schizophrenia is a genetic disorder.”
D) “Schizophrenia is due to too much dopamine in certain parts of the brain.”

Rationale:

Theories explaining the cause of schizophrenia include a genetic component, imbalances in neurotransmitters in specific areas of the brain, and overactive dopaminergic pathways in the basal nuclei. There is no evidence to support a link between schizophrenia and alcohol consumption during pregnancy. A stressful environment will exacerbate the symptoms of schizophrenia but does not cause the illness.

Question 54

Which statement regarding the pathophysiology and etiology of schizophrenia is correct?
A) “Brain imaging shows that there is reduced blood flow to the thalamus, frontal lobe, and temporal lobes.”
B) “There is an increased number of nicotinic receptors in the hippocampus, which makes it harder to form new memories and interpret sensory stimuli.”
C) “Genetics does not seem to factor into the cause of the disease.”
D) “The ventricles and sulci of the brain are decreased in size.”

Answer 54

A) “Brain imaging shows that there is reduced blood flow to the thalamus, frontal lobe, and temporal lobes.”

Rationale:

There are many abnormalities of the central nervous system in a client with schizophrenia. Brain imaging studies of individuals with schizophrenia consistently reveal a pattern of structural abnormalities that include decreased volumes of gray matter in the prefrontal cortex, temporal lobes, hippocampus, and thalamus; enlarged ventricles and sulci; and decreased blood flow to the frontal lobe, thalamus, and temporal lobes. A decreased number of nicotinic receptors in the hippocampus makes it harder for the client with schizophrenia to form new memories and interpret sensory stimuli. Genetics seems to factor into the cause of the disease, as familial patterns of the disease are noted. In the client with schizophrenia, the ventricle and sulci of the brain are increased in size.

Question 55

A nurse working in a psychiatric unit is caring for a client diagnosed with schizophrenia who manifests positive symptoms of the disease. Based on this data, which manifestation does the nurse expect to identify when providing care?
A) Social withdrawal
B) Hallucinations
C) Anhedonia
D) Concrete thinking

Answer 55

B) Hallucinations

Rationale:

The major manifestations of schizophrenia are described as either positive symptoms or negative symptoms, depending on whether they involve the presence of unusual behaviors or the absence of typical behaviors. Hallucinations are a positive symptom; all other choices are negative symptoms..