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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 requests extra blankets when the thermostat in the room indicates 80°F.
- D. A client asks when family members will be arriving after visiting 1 hr earlier.
Correct Answer: B
Rationale: Preference changes aren’t delirium-specific. Suspecting poison indicates delusional confusion, a delirium sign. Blankets in warmth suggest sensory issues, not delirium. Time confusion fits delirium, but poisoning suspicion is more acute.
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A nurse in an assisted-living facility is caring for a client who is in early stages of dementia. The client has been oriented to name and place and is usually cooperative. Which of the following nursing actions is appropriate if the client refuses to take morning medications?
- A. Notify the charge nurse of the need for evaluation of the client's level of competence.
- B. Ask the client to express her reasons for refusing the morning medications and document the event.
- C. Crush the pills, if not contraindicated, and hide them in the client's applesauce.
- D. Try to talk the client into adherence by telling her the possible implications of missing a dose.
Correct Answer: B
Rationale: Competence evaluation follows understanding refusal. Asking reasons respects autonomy and informs care. Crushing pills without consent is unethical and risky. Coercion dismisses client rights; understanding is better.
A client describes flashbacks of a terrifying car crash in which he saw his best friend die. Which disorder should the nurse suspect in this situation?
- A. Panic disorder
- B. Obsessive-compulsive disorder
- C. Posttraumatic stress disorder
- D. Agoraphobia
Correct Answer: C
Rationale: Panic disorder involves unexpected and repeated episodes of intense fear, often without a specific trigger, and isn’t typically linked to flashbacks. Obsessive-compulsive disorder is characterized by unwanted repeated thoughts (obsessions) and actions (compulsions), not trauma-related flashbacks. PTSD involves re-experiencing a traumatic event through flashbacks and nightmares, directly matching the client’s symptoms of reliving the car crash. Agoraphobia is an anxiety disorder involving fear of places or situations that might cause panic, not tied to specific traumatic memories.
A nurse is caring for a client who has an anxiety disorder. Which of the following findings should the nurse recognize as a manifestation of mild anxiety?
- A. Incoherent speech
- B. Irritability
- C. Insomnia
- D. Chest pain
Correct Answer: B
Rationale: Incoherent speech indicates severe anxiety. Irritability is a mild anxiety sign, with maintained function. Insomnia suggests chronic anxiety. Chest pain aligns with severe anxiety or panic.
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.
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.