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Terms in this set (98)Which nursing diagnosis would be the priority for the client experiencing acute delirium? Risk for injury related to confusion and cognitive deficits Which would not be considered a primary goal of nursing care for a client with delirium? Achievement of self-esteem needs The
nurse receives a report that a 75-year-old client is recovering from surgery. During the shift, the nurse notes that the client is forgetful and restless. Several times, the client calls the nurse the name of the client's daughter. The nurse interprets this behavior as what? Signs of delirium
An 80-year-old is brought to the clinic by the client's spouse. The client has a history of peripheral vascular disease and type 2 diabetes. The spouse states that the client hasn't seemed to be normal for the preceding few days, noting that the client has been lethargic and mildly confused at times and has been incontinent of urine. The spouse reports that the client's blood glucose levels have been elevated. The nurse considers which as the most likely explanation for the
client's change in mental status? Delirium related to underlying medical problem The client is an 84-year-old suffering from delirium. The client has been in a nursing home for the past 2 years but recently is
becoming combative and has become a threat to staff. Which medication would the client most likely receive for these symptoms? Haloperidol The client is 42 years old, married, and has two children, ages 16 and 18. The client is also caring for the client's parent, who is in the late stages of Alzheimer's disease. The nurse would want to assess the client
for what? Signs of stress A client was admitted to an inpatient unit with a diagnosis of dementia. A nursing assessment and interview of the client would include what? Intellectual ability, health history, and self-care ability An 82-year-old client with a diagnosis of vascular dementia has been admitted to the geriatric psychiatry unit of the hospital. In planning the care of this client, which outcome should the nurse prioritize? The client will remain free from injury. A care aide has rung the call light for assistance while providing a client's twice-weekly bath because the client became agitated and
aggressive while being undressed. Knowing that the client has a diagnosis of dementia of Alzheimer's type and is prone to agitation, which measure may help in preventing this client's agitation? Reminding the client multiple times that he or she will be soon having a bath The nurse is assessing a client who has received a tentative diagnosis of delirium. The nurse is explaining to the family about the major cause of the client's condition. Which statement by the nurse would be most appropriate? "The client's diagnosis is primarily based on the rapid onset of the change in consciousness." The client has early Alzheimer's
disease. When asked about family history, the client relates that the client has two children who are both grown and who visit the client around the holidays each year. The nurse subsequently discovers that the client has one child who is currently assigned overseas and who has not been home for 2 years. Which would best describe the client's behavior? The client is confabulating, most likely to cover for memory deficit. A client has experienced a gradual flattening of affect, confusion, and withdrawal and has been diagnosed with Alzheimer's disease. Which additional findings
would the nurse most likely assess? Personality change, wandering, and inability to perform purposeful movements To manage voiding issues, such as incontinence, male
clients diagnosed with dementia would best be managed by what? Use of disposable, adult diapers A group of friends have arrived at the hospital to visit a client recently diagnosed with delirium. The nurse tells the friends they can visit with the client one at a time. What is the likely reason for the
nurse to give this instruction? The nurse wants to prevent increasing the client's confusion. What is the greatest benefit support groups provide to the
caregivers of clients diagnosed with dementia? provides interaction with those with similar concerns A client with a medical diagnosis of dementia of Alzheimer's type has been increasingly agitated in recent days. As a result, the nurse has
identified the nursing diagnosis of "risk for injury related to agitation and confusion" and an outcome of "the client will remain free from injury." What intervention should the nurse use in order to facilitate this outcome? Monitor amount of environmental stimulation and adjust as needed. A nurse is caring for a client diagnosed with delirium who has been brought for treatment by the client's adult child. While taking the client's history, which question would be most appropriate for the nurse to ask the client's adult child? "Has your parent taken any medications recently?" Which can be identified as a hallmark symptom of dementia? Short-term memory loss The nurse documents that a client diagnosed with dementia of the Alzheimer's type is exhibiting agnosia when the client is observed being unable to ... identify a picture of a car. Which
type of hallucination most commonly occurs in clients diagnosed with dementia? Visual A client with dementia becomes extremely agitated shortly after being admitted to the psychiatric unit. The nurse is reluctant to use physical restraints to control the client. What is a likely reason the nurse has this reluctance? Physical restraints may increase the client's agitation. An older adult client develops delirium secondary to an infection. Which would be the most likely
cause? Pneumonia A client is diagnosed with Alzheimer's disease. While assessing the client, the nurse notes that the client has trouble identifying objects such as a key and spoon. The nurse would document this as what? Agnosia What is the initial intervention the nurse should implement when helping a client diagnosed with dementia deal with paranoid delusions? observe the client in order to identify the triggers for the delusions A 35-year-old client is delirious after being lost in the woods for several days and becoming severely dehydrated. At 9 p.m. the client tells the nurse to get the client's clothes because the client has to get home to the client's family. Which response by the nurse is most therapeutic? "You're in the hospital. You did not drink for several days, but you're getting better now." Which nursing diagnosis would be the priority for the client experiencing acute delirium? Risk for injury related to confusion and cognitive deficits The client is a 68-year-old who has been showing signs of Alzheimer's disease, including visual hallucinations and
disturbed behaviors. When the client was placed on antipsychotic medications, the client suffered significant adverse reactions. This could indicate that the client does not have Alzheimer's disease, but which condition? Lewy body dementia The nurse asks a client to pretend the client is brushing the client's teeth. The
client is unable to perform the action. Upon examination, the nurse finds that the client possesses intact motor abilities. What can this problem be documented as? The client may have apraxia. A client is in the mild stage of dementia due to Alzheimer's disease.
Which intervention would be most appropriate? Providing emotional support and gentle reminders A group of nursing students is reviewing
information about delirium and its causes. The students demonstrate a need for additional review when they identify which as a cause of this medical condition? Oxidative stress Major goals for the nursing care of clients with dementia should include what? The client will be safe, be physiologically stable, and have infrequent episodes of agitation. A nurse is providing education to the care provider of a cognitively impaired client who is
prescribed a cholinesterase inhibitor. Which information about medication side effects should the nurse be sure to include? Gastrointestinal (GI) symptoms When conducting a nursing assessment of a client experiencing moderate cognitive dysfunction, the nurse can best prepare for an effective interview by ensuring what? Asking a family member to be present during the assessment Which is the primary treatment for delirium? Identify and treat any causal or contributing medical conditions A nurse is caring for a client with delirium. The nurse assesses the client's activities of daily living on a daily basis. What is the most likely reason for assessing these so
frequently? To assess for fluctuation in the client's capabilities A 65-year-old has been admitted to the intensive care unit following surgical resection of the bowel. The client has developed a fever.
Which additional signs indicate the client has developed delirium? The client removes the client's surgical bandage and begins picking at the sheets. The nurse is
assessing a client who is diagnosed with delirium. Which presenting sign in the client indicates to the nurse that the client may have a diagnosis of dementia? Remote memory loss What is the initial intervention the nurse should implement when helping a client diagnosed with dementia deal with paranoid delusions? observe the client in order to identify the triggers for the delusions A client is exhibiting signs of mild delirium such as
occasional confusion about why the client is in the hospital and what day of the week it is. When developing a care plan, the nurse identifies several strategies to improve the client's cognitive function. Which intervention will be helpful to the client? Make up a daily calendar with the date and the times of scheduled activities. The spouse caregiver of a client with dementia tells the nurse that the client has been agitated lately. The spouse states, "I don't know how to handle this. The client was always such a gentle person!" Which interventions should the nurse suggest? Distract the client with family photos and discuss the events pictured. The nurse is performing an admission assessment for a client who is suspected of having dementia. Which finding would the nurse most likely document as a
subjective finding? Answers by the client and family to questions about emotional changes Which client behavior should
the nurse attempt to change when managing a client's tendency to wander and pace at night? take a nap mid-afternoon and before dinner A client with dementia is having difficulty clearly communicating about physical needs. When teaching
the caregiver about ways to assist the client in meeting physical needs, which instruction would the nurse most likely include? Keep a record of bowel movements. Which is the hallmark of beginning mild
dementia? Forgetfulness An 82-year-old client with a diagnosis of vascular dementia has been admitted to the geriatric psychiatry unit of the hospital. In planning the care of this client, which outcome should the nurse prioritize? The client will remain free from injury. When assessing a client with dementia, the nurse notes that the client is having difficulty identifying common items, such as a ball or book. The nurse interprets this finding as what? Agnosia A client diagnosed with Alzheimer's disease says, "I'm so afraid. Where am I? Where is my family?" How should the nurse respond? "You are in the hospital and you're safe here. Your family will return at 10 o'clock, which is 1 hour from now." Cognitive disorders are characterized by what? Impaired attention, memory, and abstract thinking The client is 42 years old, married, and has two children, ages 16 and 18. The client is also caring for the client's parent, who is in the late stages of Alzheimer's disease. The nurse would want to assess the client for what? Signs of stress A client with Alzheimer's disease in the intensive treatment unit repeatedly tries to go into other clients' rooms to nap during the day. The most appropriate nursing intervention for this client is what? Escorting the client to the client's room for napping A 73-year-old client has been brought to the emergency department by the client's adult children due to abrupt and uncharacteristic changes in behavior, including impairments of memory and judgment. The subsequent history and diagnostic testing have resulted in a diagnosis of delirium. Which teaching
point about the client's diagnosis should the nurse provide to the family? "If the underlying cause of delirium is identified and treated, most people return to their previous level of functioning." A client has vascular neurocognitive disorder. When teaching the family about the cause of this disorder, which would the nurse expect to integrate into the explanation? Blood flow in the vessels to the brain are blocked. The nurse is assessing a client with aphasia and notes the client may be exhibiting echolalia during their conversation. What signs does the nurse observe that leads to this conclusion? The client may echo whatever is heard. Parkinson's disease is thought to be caused by which neural change? A loss of neurons at the basal ganglia The client has advanced Alzheimer's disease and becomes confused at mealtimes. The client has agnosia, apraxia, and disturbed executive functioning. Which is the most appropriate nursing intervention? Provide the client with a tray, opening containers for the client. When giving tacrine to an elderly client, the nurse must be aware of what
information? Because the liver is most vulnerable to tacrine, liver function tests must be done periodically. Which medication is not known to cause delirium? Loop diuretics An older adult with no significant medical history is admitted to the hospital through the emergency department after hitting the client's head during a fall and fracturing the humerus. The client does not require surgery and will probably be discharged the
following day. Should the nurse be concerned about delirium? Yes, because of the head injury and medication The nurse is interviewing
a 50-year-old with a suspected cognitive disorder. The client has a long history of alcoholism. When the nurse asks if the client is employed, the client replies that the client is currently employed as a conductor on a national railway system. The client's spouse takes the nurse aside and informs the nurse that the client hasn't worked for several years and never worked for the railway. The nurse attributes the client's answer to which explanation? The client may have Korsakoff's syndrome. A client is diagnosed with dementia related to Parkinson's disease. While at a clinic visit, a cholinesterase inhibitor is prescribed for the client. The nurse knows that this type of
medication would be prescribed for the client to achieve which goal? Slow deterioration of memory and function A nurse is caring for a client with delirium. The client sees a thermometer on the nurse's table and
shouts, "Don't stab me!" and cowers. Which feature of delirium is this client exhibiting? Illusion The nurse is caring for a client with dementia. The client's brain images show atrophy of cerebral neurons and enlargement of the third and fourth ventricles. What is the cause of dementia in this client? Alzheimer's disease A nurse is preparing a presentation for a group of staff nurses about neurocognitive disorders. When describing vascular neurocognitive disorder, the nurse would identify which as posing the greatest risk for this disorder? Hypertension The nurse should consider the intervention referred to as "going along with" when managing the care of which client? the older widower who is worried about his wife not being able to visit because of the snow A client with amnestic disorder is being evaluated for dementia. Which is a diagnostic characteristic of amnestic disorder? History and physical examination indicative of memory impairment After educating a group of nurses on Alzheimer's disease and appropriate nursing care, the group leader determines that the education was successful when the nurses identify which as the foundation for providing care to the client and family? Therapeutic relationship A client with Alzheimer's disease is admitted to an acute care facility for treatment of an infection. Assessment reveals that the client is anxious. When developing the client's plan of care, which would be least appropriate for a nurse to include? Frequently provide reality orientation A client is diagnosed with dementia that has progressed significantly. Which would be the priority for this client? Safety A nurse is studying the medical chart of
a client with delirium. The nurse finds that the client was given haloperidol. What would be the most likely reason for administering this drug to the client? To decrease agitation Directed by evidence-based practice, the psychiatric nurse minimizes the milieu's dementia-induced
aggressive behavior by: adhering to a predictable dressing routine. When working with the family of an older adult client recently diagnosed with vascular dementia, the nurse's primary educational concern is to
what? Discuss the speed of progression of the disease's symptoms What is the primary sign of delirium? An altered level of consciousness A 59-year-old has just been diagnosed with early-stage dementia. The client is experiencing mild forgetfulness but can function normally. The client lives with a spouse and adult child, who is a single parent of two. When planning care for this family, which of the goals should the nurse identify as a
priority? The client will discuss emotional response to diagnosis. The geriatrician has prescribed an 80-year-old client donepezil in order
to treat the client's dementia, Alzheimer's type. Which teaching points should the nurse provide to the client's spouse about the new medication? "Donepezil won't cure your spouse's dementia of Alzheimer's type, but it has the potential to slow down the progression of the disease." A client diagnosed with Alzheimer's disease has an alteration in language ability. This alteration would
be documented as what? Aphasia A group of nurses is reviewing information about delirium and dementia. The nurses demonstrate a need for additional review when they identify which as a characteristic of dementia? Fluctuating changes within a 24-hour period A client in the client's 50s has contacted the care provider because of concerns for the client's spouse, who has suddenly begun behaving uncharacteristically in recent days. Most recently, the spouse became lost while driving to the spouse's home of 30 years and temporarily forgot the name of the spouse's child. Diagnostic testing has ruled out delirium and the spouse had been previously
healthy. What is the most likely cause of the spouse's cognitive changes? Vascular dementia The nurse understands that numerous comorbidities can contribute to the development of dementia. Which client may be at risk for dementia? A 49-year-old client whose human immunodeficiency virus (HIV) has progressed to acquired immunodeficiency syndrome (AIDS) Changes that are found during the mental status examination of a client diagnosed with delirium include what? Difficulty focusing A client has contacted the care provider because of concerns for the client's 55-year-old spouse,
who suddenly became very forgetful in recent days. Most recently, the spouse became lost while driving to the spouse's home of 30 years and temporarily forgot the client's adult child's name. The client also had a temporary slurring of speech lasting about a minute. Diagnostic testing has ruled out delirium and the spouse had been previously healthy. Which would the nurse most likely suspect? Vascular neurocognitive disorder An older client comes to the clinic for a yearly physical exam. During the assessment, the client tells the nurse that the client sometimes has begun feeling anxious about the client's forgetfulness. The nurse notes the client may have mild dementia. Which finding would lead the nurse to conclude this? The client has difficulty finding words The psychiatric nurse documents that the cognitively impaired client is exhibiting "confabulation" when observed doing what? Telling other clients that the client "was a dairy farmer" when the client actually ran a small grocery store The nurse preparing an educational program on dementia should include
which information? The onset of symptoms of dementia is gradual In clients with Alzheimer's disease, neurotransmission is reduced, neurons are lost, and the hippocampal neurons degenerate.
Which neurotransmitter is most involved in cognitive functioning? Acetylcholine Delirium can be differentiated from many other cognitive disorders in which way? It has a rapid onset and is highly treatable if diagnosed quickly. Which is the most effective intervention for clients with delirium? Managing environmental stimuli A nurse is caring for a client with delirium who is experiencing illusions. What environmental conditions should the nurse arrange for this client? provide a well-lit room without glare or shadows and limit noise The grown daughter of a woman with Alzheimer's disease reports to the nurse that she is trying to keep her mother's condition from worsening by asking her questions whenever they are together. The nurse recognizes that this activity is likely to do which of the
following? Increase frustration A new nurse has been working with clients with Alzheimer's disease for almost 6 months. During a staff meeting, the nurse expresses frustration because the same instructions have to be given to clients on a daily basis. The nurse states, "I feel like
all my work doesn't do them any good." Which suggestion would be most appropriate for the supervisor to make initially? Try to stay supportive and meet the clients' needs at the current moment. The nurse is providing care to a client with dementia to meet the client's nutritional needs. Which approach would be most appropriate for the nurse to implement to assist in meeting adequate dietary intake? Serve meals in small, bite-size pieces. During morning care, a nursing assistant asks a client with dementia, "How was your night?" The client replies, "It was lovely. My husband and I went out to dinner and to a movie." The nurse, who overhears this conversation, would make which assessment regarding the client? The client is using confabulation. A client was admitted to the intensive care unit after a motor vehicle accident. The client sustained a right parietal injury, resulting in an acute confusional state or delirium. The client reports that there are "bugs crawling around" on the arms. The nurse understands this as: tactile hallucinations from delirium. The adult child of a client with dementia asks the nurse how the adult child should respond when the client repeatedly says the client has had a busy day at work. The client has not worked in over 20 years. Which is
the best guidance that the nurse could offer? Go along with the client's thought of it having been a busy day, but do not refer to the client's work. A nurse is working with a client, and family of the client, who has a diagnosis of Alzheimer's disease. The nurse explains to the client and family that the average course of the disease is how many years? 10 While reviewing the medical record of a client with moderate dementia of
the Alzheimer's type, a nurse notes that the client has been receiving memantine. The nurse identifies this drug as which type? NMD receptor antagonist Which of the following statements by the caregiver of a client newly diagnosed with dementia requires further intervention by the nurse? "I will try to find new and different things to do every day." Which of the following interventions is most appropriate in helping a client with early-stage dementia
complete ADLs? Allow enough time for the client to complete ADLs as independently as possible. The
nurse is working with the family of a client who is newly diagnosed with Alzheimer's type dementia. Which suggestion would be effective for assisting the family members in daily orienting of their family member when the client returns home? Use daily newspapers, calendars, and a set routine. Students also viewedChapter 22 prep u12 terms GatinhoChat MED/SURG2: Chapter 5983 terms Marlaina_Clark Final Exam - Chapter 24100 terms makaela_brookePLUS Ch 24 PrepUs: Cognitive Disorders36 terms gretchen_niemi Sets found in the same folder
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How does the nurse care for a client with neurocognitive disorder?While caring for a client diagnosed with neurocognitive disorder (NCD), the nurse remains calm, undemanding, and avoids forcing the client to perform activities that he or she is refusing. Which outcome will the nurse observe in the client after this intervention?
What does the nurse conclude from the mental status examination?The nurse performs a mental status examination for a client and concludes that the client is in the first stage of neurocognitive disorder (NCD). Which mean score in the examination supports the nurse's conclusion?
What does the nurse find on assessment of the client?On assessment, the nurse also finds that the client has difficulty picking up objects. Which condition does the nurse suspect in the client? Which side effect does the nurse observe in a client with neurocognitive disorder (NCD) being treated with mirtazapine?
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Which finding would the nurse observe in a client with vascular neurocognitive disorder Quizlet
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