Chapter 14 My Nursing Test Banks

 

Kneisl, Contemporary Psychiatric-Mental Health Nursing, 3/e Test Bank
Chapter 14

Question 1

Type: MCSA

CreutzfeldtJakob disease is thought to be caused by:

1. A response to multiple medications.

2. A rare genetic disorder.

3. An infection caused by a prion.

4. Ischemic vascular disease.

Correct Answer: 3

Rationale 1: CreutzfeldtJakob disease is an infectious, transmissible degenerative dementia affecting the cerebral cortex through cell destruction and overgrowth. A very rapid onset and involuntary movements mark it. The infection is presumed to be caused by a prion, a small proteinaceous particle that is resistant to treatment and sterilization procedures.

Rationale 2: CreutzfeldtJakob disease is an infectious, transmissible degenerative dementia affecting the cerebral cortex through cell destruction and overgrowth. A very rapid onset and involuntary movements mark it. The infection is presumed to be caused by a prion, a small proteinaceous particle that is resistant to treatment and sterilization procedures.

Rationale 3: CreutzfeldtJakob disease is an infectious, transmissible degenerative dementia affecting the cerebral cortex through cell destruction and overgrowth. A very rapid onset and involuntary movements mark it. The infection is presumed to be caused by a prion, a small proteinaceous particle that is resistant to treatment and sterilization procedures.

Rationale 4: CreutzfeldtJakob disease is an infectious, transmissible degenerative dementia affecting the cerebral cortex through cell destruction and overgrowth. A very rapid onset and involuntary movements mark it. The infection is presumed to be caused by a prion, a small proteinaceous particle that is resistant to treatment and sterilization procedures.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Examine the biopsychosocial theories that explain delirium, dementia, amnestic disorders, and other cognitive disorders.

Question 2

Type: MCSA

An 82-year-old man is admitted to a medical-surgical unit for diagnostic confirmation and management of probable delirium. Which of the following statements by the clients daughter best supports the diagnosis?

1. Dad has always been so independent. Hes lived alone for years since my mom died.

2. Dad just didnt seem to know what he was doing. He would forget what he had for breakfast.

3. Maybe its just caused by aging. This usually happens by age 82.

4. The changes in his behavior came on so quickly. I wasnt sure what was happening.

Correct Answer: 4

Rationale 1: Delirium is characterized by a rapid and abrupt onset of symptoms. While delirium is more common in older individuals, aging is not a cause of delirium. Impairments in short-term memory are more indicative of dementia. The fact that he had been independent has no bearing on his current symptoms.

Rationale 2: Delirium is characterized by a rapid and abrupt onset of symptoms. While delirium is more common in older individuals, aging is not a cause of delirium. Impairments in short-term memory are more indicative of dementia. The fact that he had been independent has no bearing on his current symptoms.

Rationale 3: Delirium is characterized by a rapid and abrupt onset of symptoms. While delirium is more common in older individuals, aging is not a cause of delirium. Impairments in short-term memory are more indicative of dementia. The fact that he had been independent has no bearing on his current symptoms.

Rationale 4: Delirium is characterized by a rapid and abrupt onset of symptoms. While delirium is more common in older individuals, aging is not a cause of delirium. Impairments in short-term memory are more indicative of dementia. The fact that he had been independent has no bearing on his current symptoms.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Examine the biopsychosocial theories that explain delirium, dementia, amnestic disorders, and other cognitive disorders.

Question 3

Type: MCSA

Which symptom would indicate that a client is delirious?

1. Dehydration

2. Illusions or hallucinations

3. Unsteady gait

4. Slurred speech

Correct Answer: 2

Rationale 1: Delirium is an acute sudden-onset disorder that includes symptoms of perceptual disturbances like illusions and hallucinations. Dehydration is a cause and not a symptom of delirium. Slurred speech is a common symptom of cerebrovascular accident. An unsteady gait is a symptom of many neuromuscular diseases and is seen in later stages of dementia.

Rationale 2: Delirium is an acute sudden-onset disorder that includes symptoms of perceptual disturbances like illusions and hallucinations. Dehydration is a cause and not a symptom of delirium. Slurred speech is a common symptom of cerebrovascular accident. An unsteady gait is a symptom of many neuromuscular diseases and is seen in later stages of dementia.

Rationale 3: Delirium is an acute sudden-onset disorder that includes symptoms of perceptual disturbances like illusions and hallucinations. Dehydration is a cause and not a symptom of delirium. Slurred speech is a common symptom of cerebrovascular accident. An unsteady gait is a symptom of many neuromuscular diseases and is seen in later stages of dementia.

Rationale 4: Delirium is an acute sudden-onset disorder that includes symptoms of perceptual disturbances like illusions and hallucinations. Dehydration is a cause and not a symptom of delirium. Slurred speech is a common symptom of cerebrovascular accident. An unsteady gait is a symptom of many neuromuscular diseases and is seen in later stages of dementia.

Global Rationale:

Cognitive Level: Evaluating

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Differentiate among the various types of cognitive disorders.

Question 4

Type: MCSA

Delirium poses a serious threat to a clients:

1. Family relationships and roles.

2. Lifestyle and habits.

3. Dignity and safety.

4. Spirituality and religious beliefs.

Correct Answer: 3

Rationale 1: The acute inability to attend appropriately to the demands of the environment and communicate ones needs poses a serious threat to ones safety and dignity. Lifestyle, habits, spirituality, religious beliefs, family relationships, and roles are more likely to be impacted by chronic cognitive disorders.

Rationale 2: The acute inability to attend appropriately to the demands of the environment and communicate ones needs poses a serious threat to ones safety and dignity. Lifestyle, habits, spirituality, religious beliefs, family relationships, and roles are more likely to be impacted by chronic cognitive disorders.

Rationale 3: The acute inability to attend appropriately to the demands of the environment and communicate ones needs poses a serious threat to ones safety and dignity. Lifestyle, habits, spirituality, religious beliefs, family relationships, and roles are more likely to be impacted by chronic cognitive disorders.

Rationale 4: The acute inability to attend appropriately to the demands of the environment and communicate ones needs poses a serious threat to ones safety and dignity. Lifestyle, habits, spirituality, religious beliefs, family relationships, and roles are more likely to be impacted by chronic cognitive disorders.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: Differentiate among the various types of cognitive disorders.

Question 5

Type: MCSA

A family member expresses concern to the nurse about behavioral changes in an elderly client. What information would cause the nurse to suspect a dementia disorder?

1. Decreased enjoyment of activities that were once enjoyable

2. Problems with preparing a meal or balancing a checkbook

3. Increased complaints of physical ailments

4. Sudden disturbed sleepwake cycle

Correct Answer: 2

Rationale 1: Activities of daily life and calculation efforts are difficult for someone with dementia. Decreased enjoyment of once pleasurable activities is anhedonia, a symptom of depression. Sudden onset of a disturbed sleepwake cycle is indicative of delirium. Increased complaints of physical ailments may be the expression of somatic symptomatology.

Rationale 2: Activities of daily life and calculation efforts are difficult for someone with dementia. Decreased enjoyment of once pleasurable activities is anhedonia, a symptom of depression. Sudden onset of a disturbed sleepwake cycle is indicative of delirium. Increased complaints of physical ailments may be the expression of somatic symptomatology.

Rationale 3: Activities of daily life and calculation efforts are difficult for someone with dementia. Decreased enjoyment of once pleasurable activities is anhedonia, a symptom of depression. Sudden onset of a disturbed sleepwake cycle is indicative of delirium. Increased complaints of physical ailments may be the expression of somatic symptomatology.

Rationale 4: Activities of daily life and calculation efforts are difficult for someone with dementia. Decreased enjoyment of once pleasurable activities is anhedonia, a symptom of depression. Sudden onset of a disturbed sleepwake cycle is indicative of delirium. Increased complaints of physical ailments may be the expression of somatic symptomatology.

Global Rationale:

Cognitive Level: Evaluating

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Differentiate among the various types of cognitive disorders.

Question 6

Type: MCSA

A client has dementia of the Alzheimers type. He is no longer able to walk, and he does not recognize family members, even his wife of 52 years, when they visit him. He attempts to communicate with agitated behaviors or with occasional incoherent vocalizations. Which stage of the illness is the client in?

1. Late-stage dementia

2. Early-stage dementia

3. Middle-stage dementia

4. Late-stage confusion

Correct Answer: 4

Rationale 1: Late-stage dementia is characterized by a loss of ambulation abilities, severe memory impairments, and communication that is limited and incoherent. Early-stage dementia does not have the severe memory loss. Clients with middle-stage dementia are still able to ambulate. Late-stage confusion is not a recognized stage of dementia of the Alzheimers type.

Rationale 2: Late-stage dementia is characterized by a loss of ambulation abilities, severe memory impairments, and communication that is limited and incoherent. Early-stage dementia does not have the severe memory loss. Clients with middle-stage dementia are still able to ambulate. Late-stage confusion is not a recognized stage of dementia of the Alzheimers type.

Rationale 3: Late-stage dementia is characterized by a loss of ambulation abilities, severe memory impairments, and communication that is limited and incoherent. Early-stage dementia does not have the severe memory loss. Clients with middle-stage dementia are still able to ambulate. Late-stage confusion is not a recognized stage of dementia of the Alzheimers type.

Rationale 4: Late-stage dementia is characterized by a loss of ambulation abilities, severe memory impairments, and communication that is limited and incoherent. Early-stage dementia does not have the severe memory loss. Clients with middle-stage dementia are still able to ambulate. Late-stage confusion is not a recognized stage of dementia of the Alzheimers type.

Global Rationale:

Cognitive Level: Evaluating

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: Differentiate among the various types of cognitive disorders.

Question 7

Type: MCSA

An older adult client is observed as having several cognitive problems, including memory and attention deficits and fluctuating levels of orientation. The nurse confirms that the clients symptoms developed over a three-day period. The clients symptoms are most characteristic of:

1. Delirium.

2. Dementia.

3. Depression.

4. DAT.

Correct Answer: 1

Rationale 1: Delirium is an acute abrupt-onset condition characterized by prominent disorientation, impaired attention, and memory deficits. Dementia and dementia of the Alzheimers type (DAT) are chronic progressive disorders characterized by memory impairments that develop slowly over a longer period. Depression is a mood disorder that is characterized by a dysphoric mood or loss of interest in usual activities.

Rationale 2: Delirium is an acute abrupt-onset condition characterized by prominent disorientation, impaired attention, and memory deficits. Dementia and dementia of the Alzheimers type (DAT) are chronic progressive disorders characterized by memory impairments that develop slowly over a longer period. Depression is a mood disorder that is characterized by a dysphoric mood or loss of interest in usual activities.

Rationale 3: Delirium is an acute abrupt-onset condition characterized by prominent disorientation, impaired attention, and memory deficits. Dementia and dementia of the Alzheimers type (DAT) are chronic progressive disorders characterized by memory impairments that develop slowly over a longer period. Depression is a mood disorder that is characterized by a dysphoric mood or loss of interest in usual activities.

Rationale 4: Delirium is an acute abrupt-onset condition characterized by prominent disorientation, impaired attention, and memory deficits. Dementia and dementia of the Alzheimers type (DAT) are chronic progressive disorders characterized by memory impairments that develop slowly over a longer period. Depression is a mood disorder that is characterized by a dysphoric mood or loss of interest in usual activities.

Global Rationale:

Cognitive Level: Creating

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Analyze the differences between delirium, dementia, and depression.

Question 8

Type: MCSA

A new nurse asks the difference between dementia and delirium. The best response is:

1. The cause of delirium is unknown.

2. Delirium develops over several weeks.

3. Delirium is often confused with depression in clients over the age of 60.

4. Delirium is a common occurrence in hospitalized clients over the age of 60.

Correct Answer: 4

Rationale 1: Delirium is an acute rapid-onset condition with an etiology that can be traced to a known cause. Removal of the cause will usually result in complete recovery. Delirium is commonly experienced by hospitalized clients over the age of 60.

Rationale 2: Delirium is an acute rapid-onset condition with an etiology that can be traced to a known cause. Removal of the cause will usually result in complete recovery. Delirium is commonly experienced by hospitalized clients over the age of 60.

Rationale 3: Delirium is an acute rapid-onset condition with an etiology that can be traced to a known cause. Removal of the cause will usually result in complete recovery. Delirium is commonly experienced by hospitalized clients over the age of 60.

Rationale 4: Delirium is an acute rapid-onset condition with an etiology that can be traced to a known cause. Removal of the cause will usually result in complete recovery. Delirium is commonly experienced by hospitalized clients over the age of 60.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Analyze the differences between delirium, dementia, and depression.

Question 9

Type: MCSA

A 70-year-old client is being evaluated for dementia. Assessment indicates the client is able to recall childhood memories and some recent events, has poor self-care skills, and cries much of the day. What is the appropriate diagnosis?

1. Depression

2. Dementia

3. Delirium

4. Grief reaction

Correct Answer: 1

Rationale 1: Affective disorders, particularly depression, can be masked by symptoms suggestive of dementia. Clinical symptoms may include impaired attention and memory, apathy, and self-neglect, with no complaints of depression. The term pseudodementia has been used to describe the reversible cognitive impairments seen in depression. There is no assessment of a loss to suggest a grief reaction.

Rationale 2: Affective disorders, particularly depression, can be masked by symptoms suggestive of dementia. Clinical symptoms may include impaired attention and memory, apathy, and self-neglect, with no complaints of depression. The term pseudodementia has been used to describe the reversible cognitive impairments seen in depression. There is no assessment of a loss to suggest a grief reaction.

Rationale 3: Affective disorders, particularly depression, can be masked by symptoms suggestive of dementia. Clinical symptoms may include impaired attention and memory, apathy, and self-neglect, with no complaints of depression. The term pseudodementia has been used to describe the reversible cognitive impairments seen in depression. There is no assessment of a loss to suggest a grief reaction.

Rationale 4: Affective disorders, particularly depression, can be masked by symptoms suggestive of dementia. Clinical symptoms may include impaired attention and memory, apathy, and self-neglect, with no complaints of depression. The term pseudodementia has been used to describe the reversible cognitive impairments seen in depression. There is no assessment of a loss to suggest a grief reaction.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: Analyze the differences between delirium, dementia, and depression.

Question 10

Type: MCSA

A son brought his 73-year-old widowed father into the emergency room. The client has congestive heart failure but is under the care of a physician and has been in good health. The son was called in by the fire department after they put out a small cooking fire at the clients home. The firefighters reported that they found the client sitting in a chair mumbling incoherently, unaware of the fire and smoke. The client now appears to be drifting in and out of consciousness and is having problems keeping his attention on any one task. In this situation, the client is probably suffering from:

1. Dementia.

2. Cerebrovascular accident.

3. Delirium.

4. Depression.

Correct Answer: 3

Rationale 1: Delirium is an abrupt-onset type of confusional state marked by disorientation, impaired attention, and fluctuating consciousness. Speech may be slurred and disjointed. Dementia has a slow onset. Depression is not marked by fluctuating consciousness. There are physical symptoms, but fluctuating consciousness is not typical in clients who have experienced cerebrovascular accident.

Rationale 2: Delirium is an abrupt-onset type of confusional state marked by disorientation, impaired attention, and fluctuating consciousness. Speech may be slurred and disjointed. Dementia has a slow onset. Depression is not marked by fluctuating consciousness. There are physical symptoms, but fluctuating consciousness is not typical in clients who have experienced cerebrovascular accident.

Rationale 3: Delirium is an abrupt-onset type of confusional state marked by disorientation, impaired attention, and fluctuating consciousness. Speech may be slurred and disjointed. Dementia has a slow onset. Depression is not marked by fluctuating consciousness. There are physical symptoms, but fluctuating consciousness is not typical in clients who have experienced cerebrovascular accident.

Rationale 4: Delirium is an abrupt-onset type of confusional state marked by disorientation, impaired attention, and fluctuating consciousness. Speech may be slurred and disjointed. Dementia has a slow onset. Depression is not marked by fluctuating consciousness. There are physical symptoms, but fluctuating consciousness is not typical in clients who have experienced cerebrovascular accident.

Global Rationale:

Cognitive Level: Creating

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Analyze the differences between delirium, dementia, and depression.

Question 11

Type: MCSA

The clients family states, We dont understand what is happening to Dad. He seems better earlier in the day and then in the evening his confusion and agitation really increase. What is the best explanation for what the client is experiencing?

1. Sundowner syndrome

2. Delirium

3. Anxiety

4. Psychosis

Correct Answer: 1

Rationale 1: Sundowner syndrome, or sundowning, is understood as confused behavior when the environmental stimulation is low. It is seen in clients with delirium and dementia. The client can become increasingly agitated, disoriented, or even aggressive/paranoid or impulsive and emotional later in the day and at night.

Rationale 2: Sundowner syndrome, or sundowning, is understood as confused behavior when the environmental stimulation is low. It is seen in clients with delirium and dementia. The client can become increasingly agitated, disoriented, or even aggressive/paranoid or impulsive and emotional later in the day and at night.

Rationale 3: Sundowner syndrome, or sundowning, is understood as confused behavior when the environmental stimulation is low. It is seen in clients with delirium and dementia. The client can become increasingly agitated, disoriented, or even aggressive/paranoid or impulsive and emotional later in the day and at night.

Rationale 4: Sundowner syndrome, or sundowning, is understood as confused behavior when the environmental stimulation is low. It is seen in clients with delirium and dementia. The client can become increasingly agitated, disoriented, or even aggressive/paranoid or impulsive and emotional later in the day and at night.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Compare possible assessment findings in delirium and dementia.

Question 12

Type: MCSA

A common symptom of dementia is difficulty in recalling words. This is called:

1. Apraxia.

2. Agnosia.

3. Aphasia.

4. Dysphagia.

Correct Answer: 3

Rationale 1: Aphasia is impaired verbal communication, including difficulty in recalling words. Apraxia is the impaired ability to carry out motor activities. Agnosia is the failure to recognize or identify common objects. Dysphagia is difficulty swallowing.

Rationale 2: Aphasia is impaired verbal communication, including difficulty in recalling words. Apraxia is the impaired ability to carry out motor activities. Agnosia is the failure to recognize or identify common objects. Dysphagia is difficulty swallowing.

Rationale 3: Aphasia is impaired verbal communication, including difficulty in recalling words. Apraxia is the impaired ability to carry out motor activities. Agnosia is the failure to recognize or identify common objects. Dysphagia is difficulty swallowing.

Rationale 4: Aphasia is impaired verbal communication, including difficulty in recalling words. Apraxia is the impaired ability to carry out motor activities. Agnosia is the failure to recognize or identify common objects. Dysphagia is difficulty swallowing.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Compare possible assessment findings in delirium and dementia.

Question 13

Type: MCSA

Which change in mental status is consistently seen in delirious individuals that differentiates it from dementia?

1. Apraxia

2. Disorientation to self

3. Clouding of consciousness

4. Impaired short-term memory

Correct Answer: 3

Rationale 1: People with delirium have fluctuating consciousness, but people with dementia are as attentive as they can be and do not have clouded consciousness until terminal stages. Impaired short-term memory is consistently seen in dementia. Apraxia is the loss of purposeful movement without loss of muscle power or coordination and may or may not be seen in delirium. Disorientation to self is seen in amnesiac disorders.

Rationale 2: People with delirium have fluctuating consciousness, but people with dementia are as attentive as they can be and do not have clouded consciousness until terminal stages. Impaired short-term memory is consistently seen in dementia. Apraxia is the loss of purposeful movement without loss of muscle power or coordination and may or may not be seen in delirium. Disorientation to self is seen in amnesiac disorders.

Rationale 3: People with delirium have fluctuating consciousness, but people with dementia are as attentive as they can be and do not have clouded consciousness until terminal stages. Impaired short-term memory is consistently seen in dementia. Apraxia is the loss of purposeful movement without loss of muscle power or coordination and may or may not be seen in delirium. Disorientation to self is seen in amnesiac disorders.

Rationale 4: People with delirium have fluctuating consciousness, but people with dementia are as attentive as they can be and do not have clouded consciousness until terminal stages. Impaired short-term memory is consistently seen in dementia. Apraxia is the loss of purposeful movement without loss of muscle power or coordination and may or may not be seen in delirium. Disorientation to self is seen in amnesiac disorders.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Compare possible assessment findings in delirium and dementia.

Question 14

Type: MCSA

The dementia unit nursing staff are informed that the entire unit will be redecorated in the next two weeks. Nursing staff tell the nurse manager that this will be a problem for the clients. What particular client need is addressed by their concern?

1. A stable environment

2. Client comfort

3. Scheduling of admissions

4. Client safety

Correct Answer: 1

Rationale 1: Clients with a diagnosis of dementia need a stable environment to promote optimal orientation. Client safety, scheduling of admissions, and client comfort may or may not be impacted by the redecoration efforts.

Rationale 2: Clients with a diagnosis of dementia need a stable environment to promote optimal orientation. Client safety, scheduling of admissions, and client comfort may or may not be impacted by the redecoration efforts.

Rationale 3: Clients with a diagnosis of dementia need a stable environment to promote optimal orientation. Client safety, scheduling of admissions, and client comfort may or may not be impacted by the redecoration efforts.

Rationale 4: Clients with a diagnosis of dementia need a stable environment to promote optimal orientation. Client safety, scheduling of admissions, and client comfort may or may not be impacted by the redecoration efforts.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Compare possible assessment findings in delirium and dementia.

Question 15

Type: MCSA

Which of the following is a risk factor for the development of delirium in older adults?

1. A lack of rigorous exercise that leads to decreased cerebral blood flow

2. Decreased social interaction that leads to profound isolation and psychosis

3. Administration of multiple medications that may cause drugdrug interactions or toxicity

4. Age-related cognitive changes that make older adult clients more susceptible to changes in mental status

Correct Answer: 3

Rationale 1: Multiple medications may cause drugdrug interactions or toxicity that can cause delirium. While the older adult client is at higher risk for delirium, it is not from age-related cognitive changes. A lack of rigorous exercise will not promote delirium. Decreased social interaction can exacerbate delirium but not cause delirium.

Rationale 2: Multiple medications may cause drugdrug interactions or toxicity that can cause delirium. While the older adult client is at higher risk for delirium, it is not from age-related cognitive changes. A lack of rigorous exercise will not promote delirium. Decreased social interaction can exacerbate delirium but not cause delirium.

Rationale 3: Multiple medications may cause drugdrug interactions or toxicity that can cause delirium. While the older adult client is at higher risk for delirium, it is not from age-related cognitive changes. A lack of rigorous exercise will not promote delirium. Decreased social interaction can exacerbate delirium but not cause delirium.

Rationale 4: Multiple medications may cause drugdrug interactions or toxicity that can cause delirium. While the older adult client is at higher risk for delirium, it is not from age-related cognitive changes. A lack of rigorous exercise will not promote delirium. Decreased social interaction can exacerbate delirium but not cause delirium.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Compare possible assessment findings in delirium and dementia.

Question 16

Type: MCSA

A 79-year-old woman suffering from dementia of the Alzheimers type resides in an independent living long-term care facility. During a recent nursing visit, the client was quite upset about the loss of her frying pan. While complaining about its loss, she was holding the pan in her hand. The nurse pointed out to the client that she had the pan she was looking for. The client looked at the pan and stated, No, this is not it. The nurse knows the client is exhibiting:

1. Aphasia.

2. Agnosia.

3. Apraxia.

4. Nystagmus.

Correct Answer: 2

Rationale 1: Agnosia is the failure to recognize or identify objects despite intact sensory function. Aphasia is a language disturbance that can be expressive or receptive. Apraxia is the impaired ability to carry out motor activities despite intact motor function. Nystagmus is the involuntary movement of the eye.

Rationale 2: Agnosia is the failure to recognize or identify objects despite intact sensory function. Aphasia is a language disturbance that can be expressive or receptive. Apraxia is the impaired ability to carry out motor activities despite intact motor function. Nystagmus is the involuntary movement of the eye.

Rationale 3: Agnosia is the failure to recognize or identify objects despite intact sensory function. Aphasia is a language disturbance that can be expressive or receptive. Apraxia is the impaired ability to carry out motor activities despite intact motor function. Nystagmus is the involuntary movement of the eye.

Rationale 4: Agnosia is the failure to recognize or identify objects despite intact sensory function. Aphasia is a language disturbance that can be expressive or receptive. Apraxia is the impaired ability to carry out motor activities despite intact motor function. Nystagmus is the involuntary movement of the eye.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Compare possible assessment findings in delirium and dementia.

Question 17

Type: MCSA

A client diagnosed with Alzheimers disease has a catastrophic reaction during an activity involving simultaneous music playing and a craft project. The client starts shouting, NO, NO, NO and runs from the room. Which approach should the nurse implement?

1. Administer a PRN antianxiety medication and restrict the clients activity participation.

2. Intervene 1:1 with the client until she is calm, and then redirect her to the activity.

3. Follow the client, reassure her 1:1, and then redirect her to a less stimulating activity.

4. Discontinue the activity program since it is upsetting the clients.

Correct Answer: 3

Rationale 1: Environmental stimulus should be kept at a minimum for clients with dementia. A quiet environment will prevent sensory overload. The nurses 1:1 intervention with the client will reassure her and reduce her anxiety. Once the client is less agitated, she can be directed to a less stimulating activity.

Rationale 2: Environmental stimulus should be kept at a minimum for clients with dementia. A quiet environment will prevent sensory overload. The nurses 1:1 intervention with the client will reassure her and reduce her anxiety. Once the client is less agitated, she can be directed to a less stimulating activity.

Rationale 3: Environmental stimulus should be kept at a minimum for clients with dementia. A quiet environment will prevent sensory overload. The nurses 1:1 intervention with the client will reassure her and reduce her anxiety. Once the client is less agitated, she can be directed to a less stimulating activity.

Rationale 4: Environmental stimulus should be kept at a minimum for clients with dementia. A quiet environment will prevent sensory overload. The nurses 1:1 intervention with the client will reassure her and reduce her anxiety. Once the client is less agitated, she can be directed to a less stimulating activity.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Compare and contrast the nursing interventions and their rationales for clients with delirium and dementia.

Question 18

Type: MCSA

Which of the following nursing techniques are appropriate for therapeutic interaction with a client who has been diagnosed with Alzheimers disease?

1. Setting strict time limits and rephrasing misunderstood questions

2. Encouraging verbal and nonverbal communication, while maintaining a calm demeanor

3. Correcting errors by the client and speaking in a loud clear voice

4. Using multiple memory cues and giving several directions at once

Correct Answer: 2

Rationale 1: Nonverbal communication will become more prominent as verbal communication skills decline. A calm demeanor will reassure the client and allow for a response without sensory overload. Correcting errors by the client, speaking in a loud voice, using multiple memory cues, setting time limits, and rephrasing questions may overstimulate and increase the clients frustration and anxiety.

Rationale 2: Nonverbal communication will become more prominent as verbal communication skills decline. A calm demeanor will reassure the client and allow for a response without sensory overload. Correcting errors by the client, speaking in a loud voice, using multiple memory cues, setting time limits, and rephrasing questions may overstimulate and increase the clients frustration and anxiety.

Rationale 3: Nonverbal communication will become more prominent as verbal communication skills decline. A calm demeanor will reassure the client and allow for a response without sensory overload. Correcting errors by the client, speaking in a loud voice, using multiple memory cues, setting time limits, and rephrasing questions may overstimulate and increase the clients frustration and anxiety.

Rationale 4: Nonverbal communication will become more prominent as verbal communication skills decline. A calm demeanor will reassure the client and allow for a response without sensory overload. Correcting errors by the client, speaking in a loud voice, using multiple memory cues, setting time limits, and rephrasing questions may overstimulate and increase the clients frustration and anxiety.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Compare and contrast the nursing interventions and their rationales for clients with delirium and dementia.

Question 19

Type: MCSA

In planning care for a person with dementia, what is the most important consideration?

1. Focus on strengths and abilities

2. Discuss end-of-life issues

3. Identify problems

4. Ensure that medications are taken

Correct Answer: 1

Rationale 1: A focus on the clients strengths and abilities will maintain the clients self-esteem and sustain the client at the optimal level of self-care. Identification of problems is done during the assessment. Medications for dementia are not curative, but rather delay the progression of the disease. Discussion of end-of-life issues will need to occur but is not the priority.

Rationale 2: A focus on the clients strengths and abilities will maintain the clients self-esteem and sustain the client at the optimal level of self-care. Identification of problems is done during the assessment. Medications for dementia are not curative, but rather delay the progression of the disease. Discussion of end-of-life issues will need to occur but is not the priority.

Rationale 3: A focus on the clients strengths and abilities will maintain the clients self-esteem and sustain the client at the optimal level of self-care. Identification of problems is done during the assessment. Medications for dementia are not curative, but rather delay the progression of the disease. Discussion of end-of-life issues will need to occur but is not the priority.

Rationale 4: A focus on the clients strengths and abilities will maintain the clients self-esteem and sustain the client at the optimal level of self-care. Identification of problems is done during the assessment. Medications for dementia are not curative, but rather delay the progression of the disease. Discussion of end-of-life issues will need to occur but is not the priority.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Compare and contrast the nursing interventions and their rationales for clients with delirium and dementia.

Question 20

Type: MCSA

What is the recommendation for environmental safety when clients have poor judgment?

1. Use measures to decrease agitation.

2. Schedule ADLs at a regular time daily.

3. Turn the temperature down on the hot water heater.

4. Provide aids to assist with orientation.

Correct Answer: 3

Rationale 1: Turning the temperature down on the hot water heater will help to prevent accidental burns when bathing or washing dishes. Using therapeutic measures to decrease agitation is recommended for clients with high risk for other-directed violence. A routine daily schedule and orientation aids will structure the clients environment to promote optimal orientation.

Rationale 2: Turning the temperature down on the hot water heater will help to prevent accidental burns when bathing or washing dishes. Using therapeutic measures to decrease agitation is recommended for clients with high risk for other-directed violence. A routine daily schedule and orientation aids will structure the clients environment to promote optimal orientation.

Rationale 3: Turning the temperature down on the hot water heater will help to prevent accidental burns when bathing or washing dishes. Using therapeutic measures to decrease agitation is recommended for clients with high risk for other-directed violence. A routine daily schedule and orientation aids will structure the clients environment to promote optimal orientation.

Rationale 4: Turning the temperature down on the hot water heater will help to prevent accidental burns when bathing or washing dishes. Using therapeutic measures to decrease agitation is recommended for clients with high risk for other-directed violence. A routine daily schedule and orientation aids will structure the clients environment to promote optimal orientation.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Compare and contrast the nursing interventions and their rationales for clients with delirium and dementia.

Question 21

Type: MCSA

In a supervision session, several of the nurses discuss methods for preventing agitated and angry outbursts in clients diagnosed with dementia. One nurse appropriately suggests:

1. Ignoring the behavior.

2. Distraction or a quieter environment at the first sign of agitation.

3. Attempting a rational discussion of the issue with the client.

4. Distraction and engagement in high-energy activities.

Correct Answer: 2

Rationale 1: Distraction or a move to a quieter environment at the first sign of agitation will prevent escalation of the behavior. It will also calm the client and addresses the emotional component of the clients experience. Ignoring the behavior will allow it to escalate. Rational discussion is not possible when a client has a diagnosis of dementia. Engagement in a high-energy activity may be too stimulating for a client that is already agitated and angry.

Rationale 2: Distraction or a move to a quieter environment at the first sign of agitation will prevent escalation of the behavior. It will also calm the client and addresses the emotional component of the clients experience. Ignoring the behavior will allow it to escalate. Rational discussion is not possible when a client has a diagnosis of dementia. Engagement in a high-energy activity may be too stimulating for a client that is already agitated and angry.

Rationale 3: Distraction or a move to a quieter environment at the first sign of agitation will prevent escalation of the behavior. It will also calm the client and addresses the emotional component of the clients experience. Ignoring the behavior will allow it to escalate. Rational discussion is not possible when a client has a diagnosis of dementia. Engagement in a high-energy activity may be too stimulating for a client that is already agitated and angry.

Rationale 4: Distraction or a move to a quieter environment at the first sign of agitation will prevent escalation of the behavior. It will also calm the client and addresses the emotional component of the clients experience. Ignoring the behavior will allow it to escalate. Rational discussion is not possible when a client has a diagnosis of dementia. Engagement in a high-energy activity may be too stimulating for a client that is already agitated and angry.

Global Rationale:

Cognitive Level: Evaluating

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Compare and contrast the nursing interventions and their rationales for clients with delirium and dementia.

Question 22

Type: MCSA

Which of the following statements would be most important for staff to consider when planning delirium management for a client?

1. Provide education for family members as needed

2. Decrease all stimulation in the clients room

3. Ask the family to involve the client in all conversations and interactions

4. Sensory deprivation and overstimulation can worsen symptoms

Correct Answer: 4

Rationale 1: Structure of the clients environment should support cognitive functions. Aids for hearing or vision are necessary to prevent sensory loss or distortion. Familiar objects from home, such as slippers, robe, and photographs, may help with orientation. Easily read clocks, orientation boards, and a structured routine that includes physical activity and socialization without sensory overload will also help with orientation. Clients with delirium can exhibit hyperactivity when overstimulated.

Rationale 2: Structure of the clients environment should support cognitive functions. Aids for hearing or vision are necessary to prevent sensory loss or distortion. Familiar objects from home, such as slippers, robe, and photographs, may help with orientation. Easily read clocks, orientation boards, and a structured routine that includes physical activity and socialization without sensory overload will also help with orientation. Clients with delirium can exhibit hyperactivity when overstimulated.

Rationale 3: Structure of the clients environment should support cognitive functions. Aids for hearing or vision are necessary to prevent sensory loss or distortion. Familiar objects from home, such as slippers, robe, and photographs, may help with orientation. Easily read clocks, orientation boards, and a structured routine that includes physical activity and socialization without sensory overload will also help with orientation. Clients with delirium can exhibit hyperactivity when overstimulated.

Rationale 4: Structure of the clients environment should support cognitive functions. Aids for hearing or vision are necessary to prevent sensory loss or distortion. Familiar objects from home, such as slippers, robe, and photographs, may help with orientation. Easily read clocks, orientation boards, and a structured routine that includes physical activity and socialization without sensory overload will also help with orientation. Clients with delirium can exhibit hyperactivity when overstimulated.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Incorporate psychiatricmental health nursing strategies that support optimal memory functioning in the care of clients with cognitive disorders.

Question 23

Type: MCSA

Which of the following medications might be given to a client with Alzheimers disease to delay the rate of cognitive decline?

1. Donepezil (Aricept)

2. Quetiapine (Seroquel)

3. Valproic acid (Depakote)

4. Escitalopram (Lexapro)

Correct Answer: 1

Rationale 1: Donepezil (Aricept) is used to slow the rate of cognitive decline in Alzheimers disease. Quetiapine (Seroquel) is used to reduce or eliminate delusions and hallucinations in vascular dementia with psychosis. Escitalopram (Lexapro) is used to treat depressive symptoms in dementia with Lewy bodies. Valproic acid (Depakote) is used to reduce mood swings in Picks disease and other mood disorders.

Rationale 2: Donepezil (Aricept) is used to slow the rate of cognitive decline in Alzheimers disease. Quetiapine (Seroquel) is used to reduce or eliminate delusions and hallucinations in vascular dementia with psychosis. Escitalopram (Lexapro) is used to treat depressive symptoms in dementia with Lewy bodies. Valproic acid (Depakote) is used to reduce mood swings in Picks disease and other mood disorders.

Rationale 3: Donepezil (Aricept) is used to slow the rate of cognitive decline in Alzheimers disease. Quetiapine (Seroquel) is used to reduce or eliminate delusions and hallucinations in vascular dementia with psychosis. Escitalopram (Lexapro) is used to treat depressive symptoms in dementia with Lewy bodies. Valproic acid (Depakote) is used to reduce mood swings in Picks disease and other mood disorders.

Rationale 4: Donepezil (Aricept) is used to slow the rate of cognitive decline in Alzheimers disease. Quetiapine (Seroquel) is used to reduce or eliminate delusions and hallucinations in vascular dementia with psychosis. Escitalopram (Lexapro) is used to treat depressive symptoms in dementia with Lewy bodies. Valproic acid (Depakote) is used to reduce mood swings in Picks disease and other mood disorders.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Incorporate psychiatricmental health nursing strategies that support optimal memory functioning in the care of clients with cognitive disorders.

Question 24

Type: MCSA

A 72-year-old client has Alzheimers dementia. Her husband of 50 years is no longer able to care safely for her at home and has her placed in a long-term care facility. When her husband visits, she smiles and talks about their many travels around the world. Intrigued, the nurse asks the husband to describe his travels. The husband laughs and says, Weve never been out of the states. The clients tales are an example of:

1. Delirium.

2. Apraxia.

3. Aphasia.

4. Confabulation.

Correct Answer: 4

Rationale 1: Confabulation is the use of fantasy to fill in the memory gaps that they are unable to remember. This is an ego-protective mechanism. Difficulty in finding words and naming objects may suggest expressive aphasia, while difficulty grasping complex concepts may suggest receptive aphasia. Delirium is a disturbance of consciousness accompanied by a change in cognition unaccounted for by a preexisting or evolving dementia. Apraxia is the loss of ability to perform formerly known skills.

Rationale 2: Confabulation is the use of fantasy to fill in the memory gaps that they are unable to remember. This is an ego-protective mechanism. Difficulty in finding words and naming objects may suggest expressive aphasia, while difficulty grasping complex concepts may suggest receptive aphasia. Delirium is a disturbance of consciousness accompanied by a change in cognition unaccounted for by a preexisting or evolving dementia. Apraxia is the loss of ability to perform formerly known skills.

Rationale 3: Confabulation is the use of fantasy to fill in the memory gaps that they are unable to remember. This is an ego-protective mechanism. Difficulty in finding words and naming objects may suggest expressive aphasia, while difficulty grasping complex concepts may suggest receptive aphasia. Delirium is a disturbance of consciousness accompanied by a change in cognition unaccounted for by a preexisting or evolving dementia. Apraxia is the loss of ability to perform formerly known skills.

Rationale 4: Confabulation is the use of fantasy to fill in the memory gaps that they are unable to remember. This is an ego-protective mechanism. Difficulty in finding words and naming objects may suggest expressive aphasia, while difficulty grasping complex concepts may suggest receptive aphasia. Delirium is a disturbance of consciousness accompanied by a change in cognition unaccounted for by a preexisting or evolving dementia. Apraxia is the loss of ability to perform formerly known skills.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Incorporate psychiatricmental health nursing strategies that support optimal memory functioning in the care of clients with cognitive disorders.

Question 25

Type: MCSA

When a client with memory loss is in need of orienting cues, the most appropriate response for maintaining dignity and self-esteem would be:

1. What an unusually warm and sunny day for the 12th of November.

2. Im sure you remember to look at your calendar every day. What is todays date?

3. What is todays date? I have such a hard time keeping track.

4. You remember that yesterday was Veterans Day, dont you? Of course that would make today November 12th.

Correct Answer: 1

Rationale 1: Interjecting orienting cues into casual conversation is a less demeaning approach than one that corrects or bombards the client with questions, facts, or figures.

Rationale 2: Interjecting orienting cues into casual conversation is a less demeaning approach than one that corrects or bombards the client with questions, facts, or figures.

Rationale 3: Interjecting orienting cues into casual conversation is a less demeaning approach than one that corrects or bombards the client with questions, facts, or figures.

Rationale 4: Interjecting orienting cues into casual conversation is a less demeaning approach than one that corrects or bombards the client with questions, facts, or figures.

Global Rationale:

Cognitive Level: Creating

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Incorporate psychiatricmental health nursing strategies that support optimal memory functioning in the care of clients with cognitive disorders.

Question 26

Type: MCSA

A nurse is working with a family who is caring for their mother at home. They complain that the strain of caring for her 24 hours a day is exhausting them. What is the nurses best suggestion?

1. They place their mother in a nursing home

2. They hire a housekeeper

3. They obtain respite care to give them a break

4. They go into family therapy

Correct Answer: 3

Rationale 1: The family should be supported to obtain respite care to give them a break from the demands of caring for their mother. Respite care may support the family to continue to care for their mother. A housekeeper may help with some household needs but will be unable to care for the mother. Support groups or supportive counseling should be used instead of insight-oriented family therapy. The placement of the mother in a nursing home may be premature. Additional support such as respite care could delay institutionalization.

Rationale 2: The family should be supported to obtain respite care to give them a break from the demands of caring for their mother. Respite care may support the family to continue to care for their mother. A housekeeper may help with some household needs but will be unable to care for the mother. Support groups or supportive counseling should be used instead of insight-oriented family therapy. The placement of the mother in a nursing home may be premature. Additional support such as respite care could delay institutionalization.

Rationale 3: The family should be supported to obtain respite care to give them a break from the demands of caring for their mother. Respite care may support the family to continue to care for their mother. A housekeeper may help with some household needs but will be unable to care for the mother. Support groups or supportive counseling should be used instead of insight-oriented family therapy. The placement of the mother in a nursing home may be premature. Additional support such as respite care could delay institutionalization.

Rationale 4: The family should be supported to obtain respite care to give them a break from the demands of caring for their mother. Respite care may support the family to continue to care for their mother. A housekeeper may help with some household needs but will be unable to care for the mother. Support groups or supportive counseling should be used instead of insight-oriented family therapy. The placement of the mother in a nursing home may be premature. Additional support such as respite care could delay institutionalization.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Predict the difficulties caregivers may face when working with clients who have cognitive disorders.

Question 27

Type: MCSA

A clients daughter provides all the day-to-day care for her mother who has a diagnosis of dementia. The daughter is experiencing symptoms of insomnia, stomach pains, and frequent headaches. These symptoms may indicate that the daughter is in need of:

1. A nursing home placement for her mother.

2. Electroconvulsive treatment for depression.

3. A thorough mental status examination.

4. Supportive counseling and information about respite care.

Correct Answer: 4

Rationale 1: The daughters symptoms of insomnia, stomach pain, and headache may be somatic symptoms that are the physical expression of emotional distress related to the stress of caregiving. Supportive counseling and information about respite care may provide her with support and help in coping with stress, discouragement, and a sense of hopelessness. A mental status examination is not indicated by her symptomatology. Nursing home placement for the mother may be premature. Electroconvulsive treatment is a treatment option for a client with a diagnosis of depression that has not responded to antidepressant therapy.

Rationale 2: The daughters symptoms of insomnia, stomach pain, and headache may be somatic symptoms that are the physical expression of emotional distress related to the stress of caregiving. Supportive counseling and information about respite care may provide her with support and help in coping with stress, discouragement, and a sense of hopelessness. A mental status examination is not indicated by her symptomatology. Nursing home placement for the mother may be premature. Electroconvulsive treatment is a treatment option for a client with a diagnosis of depression that has not responded to antidepressant therapy.

Rationale 3: The daughters symptoms of insomnia, stomach pain, and headache may be somatic symptoms that are the physical expression of emotional distress related to the stress of caregiving. Supportive counseling and information about respite care may provide her with support and help in coping with stress, discouragement, and a sense of hopelessness. A mental status examination is not indicated by her symptomatology. Nursing home placement for the mother may be premature. Electroconvulsive treatment is a treatment option for a client with a diagnosis of depression that has not responded to antidepressant therapy.

Rationale 4: The daughters symptoms of insomnia, stomach pain, and headache may be somatic symptoms that are the physical expression of emotional distress related to the stress of caregiving. Supportive counseling and information about respite care may provide her with support and help in coping with stress, discouragement, and a sense of hopelessness. A mental status examination is not indicated by her symptomatology. Nursing home placement for the mother may be premature. Electroconvulsive treatment is a treatment option for a client with a diagnosis of depression that has not responded to antidepressant therapy.

Global Rationale:

Cognitive Level: Creating

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: Predict the difficulties caregivers may face when working with clients who have cognitive disorders.

Question 28

Type: MCSA

An 84-year-old woman with a diagnosis of dementia lives with her daughter and son-in-law. The clients daughter tearfully tells the nursing student that she does not know whats wrong with her mother, who has begun accusing them of stealing her lingerie and keeping her prisoner. Based on the above, the nursing student identifies the following nursing diagnosis for the client:

1. Disturbed Thought Processes.

2. Defensive Coping.

3. Powerlessness.

4. Ineffective Coping.

Correct Answer: 1

Rationale 1: Based on the assessment data, an appropriate nursing diagnosis for a client who is experiencing delusions and paranoid ideation is Disturbed Thought Processes. Powerlessness, Ineffective Coping, and Defensive Coping are nursing diagnoses more appropriate for addressing care for clients with depressive disorders or substance abuse.

Rationale 2: Based on the assessment data, an appropriate nursing diagnosis for a client who is experiencing delusions and paranoid ideation is Disturbed Thought Processes. Powerlessness, Ineffective Coping, and Defensive Coping are nursing diagnoses more appropriate for addressing care for clients with depressive disorders or substance abuse.

Rationale 3: Based on the assessment data, an appropriate nursing diagnosis for a client who is experiencing delusions and paranoid ideation is Disturbed Thought Processes. Powerlessness, Ineffective Coping, and Defensive Coping are nursing diagnoses more appropriate for addressing care for clients with depressive disorders or substance abuse.

Rationale 4: Based on the assessment data, an appropriate nursing diagnosis for a client who is experiencing delusions and paranoid ideation is Disturbed Thought Processes. Powerlessness, Ineffective Coping, and Defensive Coping are nursing diagnoses more appropriate for addressing care for clients with depressive disorders or substance abuse.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: Predict the difficulties caregivers may face when working with clients who have cognitive disorders.

Question 29

Type: MCSA

A nursing student expresses a belief that it is normal for older adults to experience forgetfulness and depression. With which of the following statements should the staff nurse respond?

1. Impairments in memory and a depressed mood are pathologic changes that require professional intervention.

2. Memory impairments are normal in older adults, but a depressed mood is not.

3. You are right. Once you pass 50, your memory is in decline.

4. Memory impairments are not normal, but a depressed mood is fairly common in older adults.

Correct Answer: 1

Rationale 1: Significant memory impairments and depressed mood are pathologic states that require professional intervention. Left untreated, clients may experience dire health consequences. Depression is often undertreated and unrecognized in older adults.

Rationale 2: Significant memory impairments and depressed mood are pathologic states that require professional intervention. Left untreated, clients may experience dire health consequences. Depression is often undertreated and unrecognized in older adults.

Rationale 3: Significant memory impairments and depressed mood are pathologic states that require professional intervention. Left untreated, clients may experience dire health consequences. Depression is often undertreated and unrecognized in older adults.

Rationale 4: Significant memory impairments and depressed mood are pathologic states that require professional intervention. Left untreated, clients may experience dire health consequences. Depression is often undertreated and unrecognized in older adults.

Global Rationale:

Cognitive Level: Creating

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: Determine your own personal feelings and attitudes that are likely to interfere with the psychiatricmental health nurses ability to care for cognitively impaired clients.

Question 30

Type: MCMA

Which questions would assist the nurse in developing self-awareness when working with clients who have cognitive disorders?

Standard Text: Select all that apply.

1. How do the clients with cognitive disorders feel about working with me?

2. How do I feel about working with clients with cognitive disorders?

3. What do the clients like about working with me?

4. How can I help the client who is confused?

5. What frustrates me about working with them?

Correct Answer: 2,5

Rationale 1: The question What do the clients like about working with me? will not increase the nurses self-awareness as it is focused on the clients needs.

Rationale 2: The question How do the clients with cognitive disorders feel about working with me? will not increase the nurses self-awareness as it is focused on the clients needs.

Rationale 3: The question What frustrates me about working with them? will increase the nurses self-awareness by focusing on the nurses feelings.

Rationale 4: The question How can I help the client who is confused? will not increase the nurses self-awareness as it is focused on the clients needs.

Rationale 5: The question How do I feel about working with clients with cognitive disorders? will increase the nurses self awareness by focusing on the nurses feelings.

Global Rationale:

Cognitive Level: Creating

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Determine your own personal feelings and attitudes that are likely to interfere with the psychiatricmental health nurses ability to care for cognitively impaired clients.

Kneisl, Contemporary Psychiatric-Mental Health Nursing, 3/e Test Bank

Copyright 2012 by Pearson Education, Inc.

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