Nokea
A client with moderate Alzheimer's disease is living with her grown daughter. Which statement by the daughter would indicate the need for intervention by the nurse?
- A. It's distressing when my mother forgets my name.
- B. I wish my sister would come to visit more often.
- C. Mother won't let anyone else do anything for her.
- D. Taking care of my mother is a big responsibility.
Correct Answer: C
Rationale: Refusing help from others increases caregiver strain, indicating a need for intervention to promote shared caregiving.
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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.
Which is the most effective intervention for clients with delirium?
- A. Giving detailed explanations
- B. Managing environmental stimuli
- C. Promoting rest with PRN medications
- D. Providing activities for distraction
Correct Answer: B
Rationale: Managing environmental stimuli reduces overstimulation, which is critical for clients with delirium.
During the change of shift report in the intensive care unit, the nurse learns that a client has developed signs of delirium over the past 8 hours. Which behavior documented in the nursing notes would be consistent with delirium?
- A. Unable to identify a water pitcher
- B. Unable to transfer to sitting position
- C. Difficulty with verbal expression
- D. Disoriented to person
Correct Answer: D
Rationale: Delirium is characterized by sudden onset and disorientation, such as to person, unlike dementia, which involves agnosia, apraxia, or aphasia.
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.
The daughter of a woman with dementia asks the nurse if her mother will ever be able to live independently again. Which would be the most appropriate response?
- A. You sound like you aren't ready for her to be dependent on caregivers.
- B. Her confusion is a temporary complication of her physical illness and should subside when the illness gets better.
- C. Symptoms of dementia gradually get worse. Unfortunately she will not be independent again.
- D. With early treatment, mild dementia can be reversed. It may be possible.
Correct Answer: C
Rationale: Dementia is progressive, leading to increasing dependence, unlike delirium, which may be reversible.