Nokea
A client voluntarily admitted to the inpatient psychiatric unit is currently experiencing mild delirium. The client approaches the nurse and states, 'I'm going to take a walk outside. I'll be back in about 10 minutes.' Which is the most appropriate nursing action?
- A. Further assess the client's motives for wanting to walk.
- B. Give the client permission to go on a walk on the grounds.
- C. Tell the client the walk is not allowed and restrict him to the unit.
- D. Designate a staff member to accompany the client on the walk.
Correct Answer: D
Rationale: Accompanying the client ensures safety due to the risk of disorientation in delirium.
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A client with dementia gets angry and begins to yell at the nurse during mealtime. The nurse leaves the client's side for 5 to 10 minutes and then returns. Which of the following best explains the nurse's behavior?
- A. The nurse was unsure of how to calm the client.
- B. The nurse was frustrated and needed to take a time-out.
- C. The nurse gave the client a chance to calm down before resuming the meal.
- D. The nurse stepped away to verify the safety of other clients.
Correct Answer: C
Rationale: Leaving briefly allows the client to calm down, leveraging their short memory to resume interaction calmly.
A client with dementia is starting pharmacotherapy to slow the progression of cognitive decline. The client has a history of moderate but steady alcohol use over the past 45 years. Which medication should the nurse question as least suitable for this client?
- A. Tacrine (Cognex)
- B. Memantine (Namenda)
- C. Donepezil (Aricept)
- D. Rivastigmine (Exelon)
Correct Answer: A
Rationale: Tacrine is less suitable due to its high risk of liver toxicity, particularly concerning given the client's history of alcohol use.
The nurse is caring for a client with Alzheimer's disease. The nurse observes that the client's pacing and mumbling to himself increase at mealtime and shift change. Which intervention should the nurse implement first?
- A. Administer an antianxiety drug such as lorazepam (Ativan) at these times.
- B. Explain the unit routine and the reasons for increased activity to the client.
- C. Keep unit activity to a minimum.
- D. Move the client to a quieter area during these times.
Correct Answer: D
Rationale: Moving the client to a quieter area reduces overstimulation, addressing the immediate cause of agitation.
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 should the nurse's supervisor encourage the nurse to do?
- A. Cease giving instructions because the clients will not remember them anyway.
- B. Try to stay supportive and meet the clients' needs at the current moment.
- C. Seek counseling if personal feelings get in the way of client care.
- D. Consider transferring to a different client care specialty area.
Correct Answer: B
Rationale: Remaining supportive and focusing on current needs helps manage frustration and maintains client-centered care.
Which is believed to be a risk factor specific to the development of delirium?
- A. Increased severity of physical illness
- B. Older age
- C. Baseline cognitive impairment
- D. Gradual decline in functioning
Correct Answer: A
Rationale: Increased severity of physical illness is a primary trigger for delirium, unlike gradual decline, which is characteristic of dementia.