Age Specific Care Quiz

Age Specific Care Quiz Related

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An elderly female client on the mental unit suddenly becomes upset because she can't remember where she is and she says, 'I can't think straight.' The staff has never witnessed this behavior in the client, and this type of complaint is not documented in the nursing history. What is the client most likely experiencing?

  • A. Hallucinations
  • B. Dementia
  • C. Delusions
  • D. Delirium
Correct Answer: D

Rationale: The correct answer is D: Delirium. Delirium is characterized by sudden onset confusion, disorientation, and impaired cognitive function. In this scenario, the elderly client's sudden confusion and inability to think straight suggest an acute change in mental status, which is indicative of delirium. Delirium is often triggered by underlying medical conditions or medications.

A: Hallucinations involve perceiving things that are not real, which is not described in the scenario.
B: Dementia is a chronic condition with gradual cognitive decline, not sudden onset confusion.
C: Delusions are fixed false beliefs, which are not mentioned in the scenario.

In summary, the client is most likely experiencing delirium due to the sudden onset of confusion and cognitive impairment, which is not consistent with hallucinations, dementia, or delusions.

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A patient with schizophrenia is admitted to the psychiatric unit in an acutely disturbed, violent state. He is given several doses of haloperidol (Haldol) and becomes calm and approachable. During rounds the nurse notices the patient has his head rotated to one side in a stiffly fixed position. His lower jaw is thrust forward and he appears severely anxious. The patient has ______, and the nurse should ______.

  • A. a dystonic reaction"¦administer PRN IM benztropine (Cogentin)
  • B. tardive dyskinesia"¦seek a change in the drug or its dosage
  • C. waxy flexibility"¦continue treatment with antipsychotic drugs
  • D. akathisia"¦administer PRN diphenhydramine (Benadryl) PO
Correct Answer: A

Rationale: The correct answer is A: a dystonic reaction"¦administer PRN IM benztropine (Cogentin).

1. Dystonic reaction is characterized by involuntary muscle contractions, causing abnormal posture or movements.
2. The patient's symptoms of head rotation, jaw thrust, and severe anxiety align with dystonic reaction.
3. Benztropine is an anticholinergic medication used to treat dystonic reactions by blocking acetylcholine in the brain.
4. Administering benztropine promptly can alleviate the symptoms and prevent complications.

Other choices are incorrect:
B: Tardive dyskinesia develops with long-term antipsychotic use, presenting as repetitive, involuntary movements. Seeking a change in drug or dosage is not appropriate for acute dystonic reaction.
C: Waxy flexibility is a symptom of catatonia, not related to the patient's presentation of dystonic reaction.
D: Akathisia is restlessness and agitation often caused by

A patient with the diagnosis of schizophrenia, disorganized type, approaches the nurse and says, "It's beat, it's eat. No room for doom." The nurse can correctly assess this verbalization as:

  • A. Neologisms
  • B. Clanging
  • C. Ideas of reference.
  • D. Associative looseness.
Correct Answer: B

Rationale: The correct answer is B: Clanging. Clanging refers to the association of words based on sound rather than meaning. In this case, the patient's verbalization "It's beat, it's eat. No room for doom" demonstrates a pattern of words that rhyme or have similar sounds but lack coherent meaning. This is characteristic of clanging seen in disorganized schizophrenia. Neologisms (A) are newly created words with unique meanings, which is not evident here. Ideas of reference (C) involve misinterpreting unrelated events as being personally significant, which is not demonstrated in the patient's statement. Associative looseness (D) is a thought disorder where ideas are loosely associated, but the patient's statement does not show this specific feature.

Which of the following can potentially be diagnostic at the clinic?

  • A. The Ages & Stages questionnaire
  • B. The Vanderbilt Rating Scale
  • C. The MCHAT R/F
  • D. The Goodenough Draw a Man test
Correct Answer: C

Rationale: The MCHAT-R/F (Modified Checklist for Autism in Toddlers, Revised with Follow-up) is a validated diagnostic screening tool for autism that can be used in a clinic setting, unlike the others which are more general developmental or cognitive assessments.

A 27-year-old woman diagnosed with borderline personality disorder displays a labile affect, impulsivity, frequent angry outbursts, and difficulty tolerating her angry feelings without self-injury. A priority nursing diagnosis for this client is:

  • A. Anxiety
  • B. Risk for self-mutilation
  • C. Risk for other-directed violence
  • D. Ineffective coping
Correct Answer: B

Rationale: The correct answer is B: Risk for self-mutilation. This is the priority nursing diagnosis because the client is displaying behaviors such as self-injury due to difficulty tolerating angry feelings. Self-mutilation poses an immediate risk to the client's safety and requires immediate intervention. The other choices are incorrect because anxiety (A) is a common symptom of borderline personality disorder but not the priority in this case. Risk for other-directed violence (C) is not indicated as the client is primarily harming themselves. Ineffective coping (D) is a broad diagnosis that does not address the immediate risk of self-mutilation.

An elderly patient brings a bag of medications to the clinic. The nurse finds a bottle labeled Ativan and one labeled lorazepam, both of which are to be taken BID. There are also bottles labeled hydrochlorothiazide, Inderal, and rofecoxib, each to be taken once daily. Which conclusion is accurate?

  • A. Rofecoxib should not be taken with Ativan.
  • B. Lorazepam interferes with the action of Inderal.
  • C. The patient should not self-administer medication.
  • D. Lorazepam and Ativan are the same drug, so the dose is excessive.
Correct Answer: D

Rationale: Lorazepam and Ativan are generic and trade names for the same drug (D), creating an accidental misuse situation with an excessive dose. The patient needs medication education and help with proper labeling; there is no evidence they cannot self-administer (C). Options A and B are not factually supported.

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