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A nurse is caring for a group of older adult clients. Which of the following client findings indicates delirium?
- A. A client expresses dislike of orange juice after reporting earlier that it was a favorite juice.
- B. A client wants to know what type of poison the nurse placed in her medication.
- C. A client asks when family members will be arriving after visiting 1 hr earlier.
- D. A client requests extra blankets when the thermostat in the room indicates 80°F.
Correct Answer: C
Rationale: Changing preferences isn’t delirium-specific. Suspecting poison suggests delusion, not necessarily delirium. Confusion about recent events, like family visits, indicates delirium’s hallmark disorientation. Requesting blankets in a warm room may reflect sensory issues, not delirium directly.
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A client with Alzheimer's disease has lost all sense of time and place and has developed visual agnosia. The client is in which of the following stages of Alzheimer's disease?
- A. Intermediate stage
- B. Severe stage
- C. End stage
- D. Early stage
Correct Answer: B
Rationale: The intermediate stage might involve moderate memory loss and some disorientation, but not typically severe symptoms like complete loss of time and place or visual agnosia. In the severe stage, clients exhibit major confusion, losing all sense of time and place, and may develop visual agnosia (inability to recognize objects), aligning with the client’s condition. The end stage involves near-total dependence and loss of physical abilities, often beyond the cognitive symptoms described. Early-stage symptoms are mild, like forgetfulness, and don’t include such advanced disorientation.
In developing a nursing care plan for an adult with a mental health disorder, the nurse knows the goals that are set must be:
- A. Important to the client
- B. Evaluated on a weekly basis
- C. Achievable by client discharge
- D. Approved by the physician
Correct Answer: A
Rationale: Client-important goals boost engagement. Weekly evaluation is useful but not mandatory. Discharge-tied goals may not fit long-term needs. Physician approval is secondary to client-centered planning.
An elderly client with severe cardiovascular disease is given the diagnosis of dementia. Which type of dementia does the client most likely have?
- A. Frontal
- B. Lewy body
- C. Alzheimer's
- D. Vascular dementia
Correct Answer: D
Rationale: Frontal (frontotemporal) dementia affects personality and behavior, not directly tied to cardiovascular issues. Lewy body dementia involves protein deposits and symptoms like hallucinations, not primarily cardiovascular-related. Alzheimer’s is common but linked to neurodegenerative changes, not specifically cardiovascular disease. Vascular dementia results from impaired blood flow to the brain, often due to cardiovascular conditions, making it the most likely here.
Which of the following mental health disorders commonly occurs in older adults?
- A. Personality disorder
- B. Depression
- C. Somatoform disorder
- D. Schizophrenia
Correct Answer: B
Rationale: Personality disorders are lifelong, not age-specific. Depression is prevalent in older adults due to health and social changes. Somatoform disorders aren’t age-specific. Schizophrenia onset is earlier, not typical in later life.
An older adult is given the diagnosis of depression and is started on medication. Which group of medications would be appropriate for the depressed older adult?
- A. Selective serotonin reuptake inhibitors (SSRIs)
- B. Benzodiazepines
- C. Hypnotics
- D. Monoamine oxidase inhibitors
Correct Answer: A
Rationale: SSRIs are often the first-line treatment for depression in older adults due to their favorable side effect profile, including lower risk of sedation and falls compared to other options. Benzodiazepines are not typically used for depression as they treat anxiety and can increase the risk of falls and confusion in older adults. Hypnotics are used for sleep issues, not as antidepressants, and don’t address the core symptoms of depression. Monoamine oxidase inhibitors are effective but often reserved for cases where other treatments fail due to their dietary restrictions and potential for serious side effects.