PN120 PrepU Chapter 24 – Flashcards
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Which nursing diagnosis would be the priority for the client experiencing acute delirium?
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Risk for injury related to confusion and cognitive deficits
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Which term is used to describe the inability to execute motor functioning, despite intact motor abilities?
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Apraxia
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What is the primary sign of delirium?
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An altered level of consciousness
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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?
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Delirium related to underlying medical problem
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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?
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Haloperidol
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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?
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Signs of stress
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A client was admitted to an inpatient unit with a diagnosis of dementia. A nursing assessment and interview of the client would include what?
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Intellectual ability, health history, and self-care ability
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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?
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The client will remain free from injury.
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A client diagnosed with Alzheimer's disease has an alteration in language ability. This alteration would be documented as what?
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Aphasia
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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?
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"The client's diagnosis is primarily based on the rapid onset of the change in consciousness."
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A nurse is assessing a client diagnosed with Alzheimer's disease. As part of the assessment, the nurse asks the client to identify common objects. The nurse is assessing for what?
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Agnosia
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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?
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Illusion
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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?
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Physical restraints may increase the client's agitation.
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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?
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The nurse wants to prevent increasing the client's confusion.
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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?
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Alzheimer's disease
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A nurse's 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 Alzheimer's disease and is prone to agitation, which measure may help in preventing this client's agitation?
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Reminding the client multiple times that he or she will be soon having a bath
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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?
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Blood flow in the vessels to the brain are blocked.
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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?
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Agnosia
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What is the greatest benefit support groups provide to the caregivers of clients diagnosed with dementia?
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provides interaction with those with similar concerns
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The nurse should consider the intervention referred to as "going along with" when managing the care of which client?
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the older widower who is worried about his wife not being able to visit because of the snow
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Delirium can be differentiated from many other cognitive disorders in which way?
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It has a rapid onset and is highly treatable if diagnosed quickly.
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The psychiatric nurse documents that the cognitively impaired client is exhibiting "confabulation" when observed doing what?
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Telling other clients that the client "was a dairy farmer" when the client actually ran a small grocery store
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A client diagnosed with Alzheimer's disease says, "I'm so afraid. Where am I? Where is my family?" How should the nurse respond?
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"You are in the hospital and you're safe here. Your family will return at 10 o'clock, which is 1 hour from now."
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Which is the primary treatment for delirium?
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Identify and treat any causal or contributing medical conditions
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Which is the priority intervention for a client diagnosed with delirium?
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Maintenance of safety
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Which is the hallmark of beginning mild dementia?
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Forgetfulness
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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?
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Make up a daily calendar with the date and the times of scheduled activities.
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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?
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The client will discuss emotional response to diagnosis.
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The client with dementia often cannot clearly communicate physical needs. Which intervention should the nurse teach the caregiver to address common physical problems?
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Keep a record of bowel movements.
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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?
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Escorting the client to the client's room for napping
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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:
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tactile hallucinations from delirium.
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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?
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Use daily newspapers, calendars, and a set routine.
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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?
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"If the underlying cause of delirium is identified and treated, most people return to their previous level of functioning."
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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?
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Monitor amount of environmental stimulation and adjust as needed.
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The nurse understands that numerous comorbidities can contribute to the development of dementia. Which client may be at risk for dementia?
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A 49-year-old client whose human immunodeficiency virus (HIV) has progressed to acquired immunodeficiency syndrome (AIDS)
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Changes that are found during the mental status examination of a client diagnosed with delirium include what?
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Difficulty focusing
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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?
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To decrease agitation
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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?
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Agnosia
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The client is 79 years old and has been diagnosed with dementia. Continuing assessment reveals that the client's condition is progressing significantly. Which would be the priority when providing care?
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Safety
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A nurse is preparing a presentation for a group of staff nurses about neurocognitive disorders. When describing vascular neuorocognitive disorder, the nurse would identify which as posing the greatest risk for this disorder?
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Hypertension
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Parkinson's disease is thought to be caused by which neural change?
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A loss of neurons at the basal ganglia
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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?
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Gastrointestinal (GI) symptoms
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When conducting a nursing assessment of a client experiencing moderate cognitive dysfunction, the nurse can best prepare for an effective interview by ensuring what?
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Asking a family member to be present during the assessment
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The diagnosis of delirium is supported when the nurse notes which in the client?
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The is convinced that the client sees "hundreds" of bugs and is not always oriented to time and place
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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 ...
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identify a picture of a car.
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A client with Alzheimer's disease has a nursing diagnosis of risk for injury related to memory loss, wandering, and disorientation. Which nursing intervention should appear in this client's care plan to prevent injury?
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Remove hazards from the environment.
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Which is an infection-related cause of delirium?
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Pneumonia
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Which type of hallucination is most commonly seen in clients diagnosed with delirium?
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Visual
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Cognitive disorders are characterized by what?
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Impaired attention, memory, and abstract thinking
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A client has experienced a gradual flattening of affect, confusion, and withdrawal and has been diagnosed with Alzheimer's disease. The nurse assesses which additional characteristics of this disorder?
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Personality change, wandering, and inability to perform purposeful movements
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A client with amnestic disorder is being evaluated for dementia. Which is a diagnostic characteristic of amnestic disorder?
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History and physical examination indicative of memory impairment
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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?
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"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."
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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?
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To assess for fluctuation in the client's capabilities
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Which is the priority when caring for a client with delirium?
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Identifying the cause
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A client is diagnosed with dementia that has progressed significantly. Which would be the priority for this client?
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Safety
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After teaching a group of nursing students about drugs used to treat Alzheimer's disease, the instructor determines that additional teaching is needed when the group identifies which as a N-methyl-D-aspartic acid (NMDA) receptor antagonist?
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Memantine
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A older adult client develops delirium secondary to an infection. Which would be the most likely cause?
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Pneumonia
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Which would be the priority goal for a client with dementia?
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Safety
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An 80-year-old client with Alzheimer's disease is prescribed donepezil. Which teaching points should the nurse provide to the client's spouse about the new medication?
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"The drug won't cure the client's Alzheimer's, but it has the potential to slow down the progression of the disease."
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Which client behavior should the nurse attempt to change when managing a client's tendency to wander and pace at night?
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take a nap mid afternoon and before dinner
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While reviewing the medical record of a client with moderate dementia of the Alzheimer type, a nurse notes that the client has been receiving memantine. The nurse identifies this drug as which type?
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N-methyl-D-aspartate (NMDA) receptor antagonist
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A client with dementia is having difficulty finding the words that the client wants to use. When the client could not remember the name of the client's shoes, he referred to them as, "the things you put on your feet." What is the name for this condition?
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Aphasia
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Which can be identified as a hallmark symptom of dementia?
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Short-term memory loss
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A client is diagnosed with dementia related to Parkinson's disease. While at a doctor's visit, a cholinesterase inhibitor is prescribed for the client. The nurse knows that this type of medication would be prescribed for the client to do what?
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Slow deterioration of memory and function
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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?
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The client is confabulating, most likely to cover for memory deficit.
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The nurse preparing an educational program on dementia should include which information?
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The onset of symptoms of dementia is gradual
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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?
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Signs of delirium
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Which is a metabolic cause of delirium?
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Hypoglycemia
