Nokea
A nurse working in an assisted living facility is holding an in-service for the nursing assistants. The nurse reviews common behaviors associated with cognitive deterioration associated with dementia. Which would cause the nurse to know that the assistants correctly understood if it were expressed during a postsets?
- A. The clients should be able to ask us for items they need
- B. The clients may not recognize their family when they come to visit
- C. The clients who are ambulatory can still carry out activities of daily living independently
- D. The clients should know when to come to the dining room for meals
Correct Answer: B
Rationale: Dementia involves agnosia, leading to failure to recognize familiar people, unlike intact executive functioning or independent ADLs.
You may also like to solve these questions
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.
Which client would have an increased risk for delirium?
- A. An elderly woman with abdominal pain
- B. A 3-year-old child with a temperature of 103.2 F
- C. A middle-aged woman newly diagnosed with multiple sclerosis
- D. A young adult male with gastroenteritis and dehydration
Correct Answer: B
Rationale: High fever in young children significantly increases the risk of delirium, more so than the other conditions listed.
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.
The grown daughter of a woman with Alzheimer's disease reports to the nurse that she is trying to keep her mother's condition from worsening by asking her questions whenever they are together. Which will be accomplished by this intervention?
- A. Decrease environmental misinterpretation
- B. Improve memory retention
- C. Increase frustration
- D. Slow the progress of the disease
Correct Answer: C
Rationale: Questioning clients with Alzheimer's about tasks they cannot perform increases frustration due to their progressive cognitive decline.
The nurse is working with a client who has hallucinations and delusions. The client tells the nurse she cannot take a shower because she is waiting for her husband to take her home. Which response by the nurse is best in this situation?
- A. It would be best if you just took your shower now.
- B. You seem anxious and upset.
- C. You have plenty of time to shower before it's time to go home.
- D. Why are you thinking you're going home?
Correct Answer: C
Rationale: Going along with the delusion without reinforcing it allows the client to proceed with activities calmly.