Nokea
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.
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The nurse encourages the client with dementia to meet nutritional needs. Which is the best approach to assist in meeting adequate dietary intake?
- A. Sit with the client as long as necessary to complete the meal.
- B. Provide entertainment during meals such as television or music.
- C. Avoid between-meal snacks to encourage appetite.
- D. Serve meals in small, bite-size pieces.
Correct Answer: D
Rationale: Serving food in bite-size pieces accommodates motor difficulties and reduces frustration during meals.
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.
A client voluntarily admitted to the inpatient psychiatric unit is currently experiencing mild delirium. The client approaches the nurse and states, 'I'm going to take a walk outside. I'll be back in about 10 minutes.' Which is the most appropriate nursing action?
- A. Further assess the client's motives for wanting to walk.
- B. Give the client permission to go on a walk on the grounds.
- C. Tell the client the walk is not allowed and restrict him to the unit.
- D. Designate a staff member to accompany the client on the walk.
Correct Answer: D
Rationale: Accompanying the client ensures safety due to the risk of disorientation in delirium.
The caregiver of a client with Alzheimer's disease reports to the nurse that often the client will suddenly become angry during meals and nothing seems to calm him down. The nurse teaches the caregiver to use distraction techniques. Which response would be best to teach as an example of this technique?
- A. Let's look at what is on television.
- B. If you stop yelling, I will get your dessert.
- C. Don't you want to finish your meal?
- D. I don't understand what you are saying.
Correct Answer: A
Rationale: Distraction, such as watching television, redirects the client's focus and helps de-escalate agitation.
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.