Nokea
The nurse is assessing a client with early signs of dementia. What is the nurse trying to determine when the nurse asks the client what he ate for breakfast that morning?
- A. Orientation
- B. Food preferences
- C. Recent memory
- D. Remote memory
Correct Answer: C
Rationale: Asking about breakfast assesses recent memory, which is typically impaired early in dementia.
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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.
The adult son of a client with dementia asks the nurse how he should respond when his mother repeatedly says she has had a busy day at work. The mother has not worked in over 20 years. Which is the best guidance that the nurse could offer?
- A. Ask her to explain what she did at work today that kept her busy.
- B. Go along with her thought of it having been a busy day, but do not refer to her work.
- C. Reorient her that she is at home and did not go to work.
- D. Give her 5 to 10 minutes of rest, and she will have no memory of the incident.
Correct Answer: B
Rationale: Going along without reinforcing the delusion provides emotional reassurance and reduces distress.
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.
Which patient is most likely suffering from dementia?
- A. A 90-year-old male who has experienced progressive mental decline that started with forgetfulness
- B. An 80-year-old female who has been in excellent health until she was admitted through the emergency department with a severe urinary tract infection and is now very anxious and is threatening staff
- C. A 6-year-old child who has just been administered conscious sedation for a closed reduction of a fractured wrist and says that her parents have three sets of eyes
- D. A 22-year-old male who was involved in a motorcycle crash without wearing a helmet now unable to remember where he is
Correct Answer: A
Rationale: Dementia involves progressive memory impairment starting with forgetfulness, unlike delirium or amnestic disorders seen in the other cases.
Which statement made by the nurse would be most appropriate to an 89-year-old patient who is confused but has no history of dementia and is hospitalized for an acute urinary tract infection?
- A. You are likely to become progressively more confused now.
- B. This should be just a temporary situation.
- C. Don't worry about it, everyone is confused when they are in the hospital.
- D. I know things are upsetting and confusing right now, but your confusion should clear as you get better.
Correct Answer: D
Rationale: This response validates the patient's feelings while providing reassurance that delirium from the infection is typically temporary.