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Which student statement indicates that learning has occurred regarding risk factors for the development of delirium in older adults?
1. "Taking multiple medications may lead to adverse interactions or toxicity."
2. "Age-related cognitive changes may lead to alterations in mental status."
3. "Lack of rigorous exercise may lead to decreased cerebral blood flow."
4. "Decreased social interaction may lead to profound isolation and psychosis."
ans 1. "Taking multiple medications may lead to adverse interactions or toxicity."
A client diagnosed with vascular dementia is discharged to home under the care of his spouse. Which information causes the nurse to question the client's safety?
1. His spouse works from home in telecommunication.
2. The client has worked the night shift his entire career
3. His spouse has minimal family support.
4. The client smokes one pack of cigarettes per day.
4. The client smokes one pack of cigarettes per day.
A client diagnosed with a neurocognitive disorder (NCD) due to Alzheimer's disease can no longer ambulate, does not recognize family members, and communicates with agitated behaviors and incoherent verbalizations. The nurse recognizes that these symptoms indicate which stage of the illness? '
1. Moderate cognitive decline
2. Very mild change
3. Moderately severe cognitive decline
4. Very severe cognitive decline
4. Very severe cognitive decline
Which nursing intervention would take priority for a client in the late stage of Alzheimer's disease?
1. Improve cognitive status by encouraging involvement in social activities.
2. Decrease social isolation by providing group therapies.
3. Promote dignity by providing comfort, safety, and self-care measures.
4. Facilitate communication by providing assistive devices
3. Promote dignity by providing comfort, safety, and self-care measures.
A client is experiencing progressive changes in memory that have interfered with personal, social, and occupational functioning. The client exhibits poor judgment and has a short attention span. The nurse recognizes these as classic signs of which condition?
1. Mania
2. Delirium
3. NCD
4. Parkinsonism
ans 3. NCD
A nursing instructor is teaching about donepezil. A student asks, "How does this work? Will this cure Alzheimer's disease?" Which reply by the instructor is appropriate?
1. "Donepezil delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the disease."
2. "Donepezil encourages production of acetylcholine, a chemical in the brain necessary for memory processes. It delays the progression of the disease."
3. "Donepezil delays the destruction of dopamine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the disease."
4. "Donepezil encourages production of dopamine, a chemical in the brain necessary for memory processes. It delays the progression of the disease."
1. "Donepezil delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the disease."
Which nursing student statement requires further teaching regarding care for the client with NCD experiencing hallucinations?
1. "I will assess for side effects of medications that could cause hallucinations."
2. "My client wears a hearing aid. I need to ensure it is working properly."
3. "If I am not experiencing the hallucination, then it is likely the client is not either."
4. "I took the mirror off the wall because the client was seeing a false image."
ans 3. "If I am not experiencing the hallucination, then it is likely the client is not either."
At which time during a 24-hour period should a nurse expect clients with Alzheimer's disease to exhibit more pronounced symptoms?
1. When they first awaken
2. In the middle of the night
3. At twilight
4. After taking medications
ans 3. At twilight
A client diagnosed with NCD has progressive memory loss, diminished cognitive functioning, verbal aggression, and is experiencing frustration. Which nursing intervention is most appropriate?
1. Schedule structured daily routines.
2. Minimize environmental lighting.
3. Organize a group activity to present reality.
4. Explain the consequences for aggressive behaviors.
ans 1. Schedule structured daily routines.
After 1 week of continuous mental confusion, an elderly African American client is admitted with a preliminary diagnosis of a major NCD due to Alzheimer's disease. Which statement would cause the nurse to question this diagnosis?
1. NCDs do not typically occur in African American clients.
2. The symptoms presented are more indicative of parkinsonism.
3. NCD does not develop suddenly.
4. There has been no triiodothyronine or thyroxine level evaluation ordered.
ans 3. NCD does not develop suddenly.
A client diagnosed with an NCD due to late-stage Alzheimer's disease is incapable of performing ADLs. Which intervention is the nurse's priority?
1. Present evidence of objective reality to improve cognition.
2. Design a bulletin board to represent the current season.
3. Label the client's room with name and number.
4. Assist the client with bathing and toileting
ans 4. Assist the client with bathing and toileting
A client diagnosed with an NCD is exhibiting behavioral problems every day. At change of shift, the client's behavior escalates from pacing to screaming and flailing. Which action would the nurse implement first?
1. Consult the psychologist regarding behavior-modification techniques.
2. Medicate the client with prn antianxiety medications.
3. Assess environmental triggers and potential unmet needs.
4. Anticipate the behavior, and restrain when pacing begins.
ans 3. Assess environmental triggers and potential unmet needs.
A client with a history of cerebrovascular accident is brought to an emergency department experiencing memory problems, confusion, and disorientation. Based on this client's assessment data, which diagnosis would the nurse expect the physician to assign?
1. Medication-induced delirium
2. VNCD
3. Altered thought processes
4. Alzheimer's disease
ans 2. VNCD
An elderly client recently moved to a nursing home. The client is having trouble concentrating and is isolating from others. A physician believes the client would benefit from medication therapy. Which medication would the nurse expect the physician to prescribe?
1. Haloperidol
2. Donepezil
3. Diazepam
4. Sertraline
ans 4. Sertraline
A client diagnosed with an NCD due to Alzheimer's disease is disoriented, ataxic, and wanders. Which nursing diagnosis is the priority?
1. Disturbed thought processes
2. Self-care deficit
3. Risk for injury
4. Altered health-care maintenance
ans 3. Risk for injury
Which action would the nurse take to promote safety in the client with an NCD?
1. Keep the client in the room furthest from the nurse's station.
2. Provide the client with glass items instead of disposable items.
3. Keep the bed in high position.
4. Encourage the client to call for assistance when getting out of bed.
ans 4. Encourage the client to call for assistance when getting out of bed.
A client was admitted to the hospital after being treated in the emergency department for seizures following a head trauma. Within a few minutes of arriving on the floor, the admitting nurse noticed that the client had a difficult time sustaining attention and did not know where she was. Which statement describes the rationale for the abnormal behavior?
1. The client likely has a systemic illness.
2. The client is experiencing delirium.
3. The client is experiencing a metabolic imbalance from dehydration.
4. The client likely has a major NCD.
ans 2. The client is experiencing delirium.
A client diagnosed with Lewy body dementia has been prescribed an antipsychotic medication to manage a decline in mental capacities. Why would the nurse question this prescription?
1. Antipsychotic medications can cause Lewy body dementia to become a permanent condition.
2. Lewy body dementia does not affect cognitive functioning.
3. Clients with Lewy body dementia are highly sensitive to the extrapyramidal effects of antipsychotic medications.
4. Lewy body dementia causes an increase in acetylcholinesterase concentrations, which makes antipsychotic medications contraindicated
ans 3. Clients with Lewy body dementia are highly sensitive to the extrapyramidal effects of antipsychotic medications.
A 36-year-old is admitted to the emergency department at 2:20 a.m. with a severe laceration to her forehead and incoherent speech. Paramedics report that they picked up the client at a local bar, and the bartender onsite said, "She seemed just fine when she came in. She must have had a lot to drink before she came here." Witness reports onsite confirmed that the woman fell off a bar stool and hit her head on the bar rail. Based on the information provided, a blood alcohol test was administered, and her blood alcohol content was 0.01%. The client's weight was recorded at 145 lbs. Incoherent speech is most likely attributed to which of the following?
1. Alcohol intoxication
2. Intoxication and fatigue due to the late hour
3. A primary NCD
4. A secondary NCD
ans 4. A secondary NCD
The nurse notices that Martha, the primary caregiver for her spouse with Alzheimer's disease, seems distracted, and she asks how Martha is doing. "I'm doing OK," said Martha. "I'm just so overwhelmed. I can't seem to get anything done. Just when I think I'm handling everything, something else comes up. Hopefully things will settle down soon, and I can get a break." Which intervention would most help Martha cope with the caregiver strain she's expressing?
1. Teaching about symptoms of Alzheimer's disease
2. Information about the management of Alzheimer's disease
3. Referrals to support services for Alzheimer's disease
4. Recommending an Alzheimer's-friendly residence facility
ans 3. Referrals to support services for Alzheimer's disease
Which nursing diagnosis is appropriate for a client who is unable to identify objects, confabulating, screaming, and demanding verbalizations?
1. Impaired verbal communication
2. Disturbed sensory perception
3. Situational low self-esteem; grieving
4. Disturbed thought processes; impaired memo
ans 1. Impaired verbal communication
On which teaching topics would the nurse focus for a caregiver of a client with stage 5 Alzheimer's disease? Select all that apply.
1. How to assist with some ADLs, such as hygiene, dressing, and grooming
2. How to care for decubitus ulcers resulting from immobility
3. How to apply medications to compromised skin resulting from bowel and bladder incontinence
4. Tools to help reorientate the client to time and place
ans 1. How to assist with some ADLs, such as hygiene, dressing, and grooming
4. Tools to help reorientate the client to time and place
Which nursing interventions would be used for a client with a nursing diagnosis of risk of trauma related to impairments in cognitive and psychomotor functioning? Select all that apply.
1. Store frequently used items within easy access.
2. Keep cigarettes and lighters out of reach of the client.
3. Keep the side rails up when the client is in bed.
4. Keep a dim light on at night.
ans 1. Store frequently used items within easy access.
2. Keep cigarettes and lighters out of reach of the client.
4. Keep a dim light on at night.
The nurse is caring for an older adult client with an NCD who becomes agitated. Which intervention by the nurse is appropriate? Select all that apply.
1. Demand the client attend a group activity session.
2. Administer an antipsychotic medication as prescribed.
3. Restrain the client immediately. 4. Encourage doll therapy.
5. Attempt to reason with the client.
6. Perform relaxation techniques.
2. Administer an antipsychotic medication as prescribed.
4. Encourage doll therapy.
6. Perform relaxation techniques.
A client in stage 3 Alzheimer's disease frequently wanders. Which interventions can the nurse implement to reduce the incidence of wandering and promote safety? Select all that apply.
1. Keep the client on a strict toileting schedule
2. Allow the client a large, unrestricted area to wander.
3. Walk with the individual and redirect them back to the unit.
4. Ensure the exits are not electronically controlled.
5. Keep the client on a structured schedule of activities.
1. Keep the client on a strict toileting schedule
3. Walk with the individual and redirect them back to the unit.
5. Keep the client on a structured schedule of activities.
____________________ is the inability to perform motor activities despite intact motor function.
1. Apraxia
2. Aphasia
3. Dementia
4. Delirium
ans 1. Apraxia
