Nokea
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.
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The daughter of a client with dementia has been the primary caregiver for 5 months. The daughter expresses to the nurse, 'At times it is so overwhelming! I feel I do not have a life anymore!' Which is the most helpful response by the nurse?
- A. Are you saying you don't want to care for your mother anymore?
- B. I know it is really hard. It takes a lot of work and you are doing such a good job.
- C. Your mother really appreciates what you do for her. You are the best one to care for her.
- D. Here is the number of a caregivers' support group. How do you think you would feel talking with others in the same situation?
Correct Answer: D
Rationale: Offering a support group provides practical help and emotional validation for the caregiver's stress.
Which is believed to be a risk factor specific to the development of delirium?
- A. Increased severity of physical illness
- B. Older age
- C. Baseline cognitive impairment
- D. Gradual decline in functioning
Correct Answer: A
Rationale: Increased severity of physical illness is a primary trigger for delirium, unlike gradual decline, which is characteristic of dementia.
A client with dementia is unable to recognize ordinary objects, such as a pen or notebook. Which would this be a symptom of?
- A. Agnosia
- B. Amnesia
- C. Apraxia
- D. Aphasia
Correct Answer: A
Rationale: Agnosia is the inability to recognize familiar objects, a hallmark of dementia, distinct from memory loss (amnesia), motor impairment (apraxia), or language deterioration (aphasia).
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.
The nurse is performing a health history with a client exhibiting signs of delirium. The nurse asks the client and family members about possible causes of the delirious state. Which would the nurse likely attribute as underlying causes for the client's delirium? Select all that apply.
- A. Recent alcohol use
- B. Dehydration
- C. Use of antihistamines
- D. Sleep disturbances
- E. Use of megadoses of vitamins
- F. Exposure to paint or gasoline
Correct Answer: A,B,C,D,F
Rationale: Delirium can be triggered by alcohol, dehydration, antihistamines, sleep disturbances, and exposure to toxins like paint or gasoline, but not typically by megadoses of vitamins.