Chapter 22: Cognitive Responses and Organic Mental Disorders My Nursing Test Banks

Chapter 22: Cognitive Responses and Organic Mental Disorders

Test Bank

MULTIPLE CHOICE

1. An individual brought to the emergency room fights against the restraints and shouts incoherently. The history reveals that the patient was weak and confused on awakening this morning and soon began rambling and talking crazy. A nurse notes that the patients skin is flushed and dry. The priority nursing action is to:

a.

assess vital signs.

b.

insert an intravenous catheter.

c.

request a sedative prescription.

d.

perform a mental status examination.

ANS: A

The patients history suggests a physiological basis for the cognitive disturbance. Vital signs will tell the nurse more about the patients physical condition.

DIF:Cognitive Level: ApplicationREF:Text Page: 429

TOP:Nursing Process: Assessment

MSC:NCLEX: Physiological Integrity: Physiological Adaptation

2. An individual is brought to the emergency room after family reports that the patient awoke confused and began rambling and talking crazy about 3 hours ago. The patient strikes out at the staff and shouts, Youre not going to kill me! The most likely analysis of this behavior is:

a.

disturbed self-esteem related to catastrophic reaction.

b.

disturbed sensory perception related to altered brain function.

c.

other-directed violence related to fear associated with hospitalization.

d.

impaired environmental interpretational syndrome related to metabolic disturbance.

ANS: B

Defining characteristics of sensory-perceptual alteration are present. For impaired environmental interpretational syndrome to be diagnosed, the confused state must have been present for 3 to 6 months. There is no reported history of a catastrophic event while the presence of the other assessment data makes fear associated with hospitalization a less likely reason for striking out at staff.

DIF:Cognitive Level: AnalysisREF:Text Page: 405

TOP:Nursing Process: Diagnosis|Nursing Process: Analysis

MSC:NCLEX: Physiological Integrity: Physiological Adaptation

3. An individual was brought to the emergency room with impaired cognitive function. The patients aggressive behavior and attempts to get out of bed present a safety issue. The nurse should first:

a.

apply four-point restraints.

b.

use a calm tone to orient the patient.

c.

assign staff to stay in the room with the patient.

d.

call for security guards to assist with controlling the patient.

ANS: B

Reality orientation is generally helpful to patients with cognitive impairment. A patient who is misinterpreting reality should be reoriented by a nurse who uses a calm manner and soothing voice. Reorientation is the least restrictive way of addressing the behaviors. Restraints or holding the patient down would increase agitation; assigning staff to stay with the patient continuously is not appropriate as an initial intervention.

DIF:Cognitive Level: AnalysisREF:Text Page: 423

TOP:Nursing Process: Implementation

MSC:NCLEX: Safe, Effective Care Environment: Management of Care

4. An individual being treated in the emergency room is found to have flushed, dry skin and sensorium that alternates between clouded and clear. A friend reveals the patient has not voided or ingested food or fluid in 18 hours. When the health care provider diagnoses fever of unknown origin, the plan is to make an effort to orally hydrate before attempting to start an IV line. The intervention most likely to be effective will be:

a.

placing a pitcher of water at the patients bedside.

b.

placing a force fluids sign at the head of the bed.

c.

asking the friend to give the patient a drink whenever the patient is alert.

d.

staying with the patient to ensure that a glass of liquid is ingested once every hour.

ANS: D

The nurse should assume or delegate responsibility for providing fluids hourly. The remaining options are unlikely to result in substantial intake.

DIF:Cognitive Level: ApplicationREF:Text Page: 405

TOP:Nursing Process: Implementation

MSC:NCLEX: Physiological Integrity: Basic Care and Comfort

5. An adult was brought to the emergency room. The patients sensorium alternates between clouded and clear, and the patient becomes agitated both physically and verbally when approached. The patients roommate states, The patient was fine after getting up this morning but started talking crazy about 3 hours ago. The patients cognitive impairment is most consistent with:

a.

delirium.

b.

dementia.

c.

sundown syndrome.

d.

early-onset Alzheimer disease.

ANS: A

Delirium is the behavioral response to widespread disturbances in cerebral metabolism and usually represents a sudden decline from the previous level of functioning. It usually is considered a medical emergency.

DIF:Cognitive Level: ComprehensionREF:Text Pages: 404-405

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

6. A widowed patient tells a nurse that the door should be left unlocked because her husband will be coming home soon. Which response by the nurse would be most therapeutic?

a.

Youve forgotten that your husbands dead, havent you?

b.

Just try to sleep. He wont be home for a very long time yet.

c.

You must miss him a lot. It almost seems hes here with you.

d.

Your husband died over 10 years ago. He wont be coming here.

ANS: C

An empathic response is always helpful, as is gentle, diplomatic reorientation. Abrupt confrontation with reality will increase anxiety, but implicitly agreeing that the spouse will come home fosters false hope.

DIF:Cognitive Level: ApplicationREF:Text Page: 426

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

7. A patient has sundown syndrome. The nurse can expect that the patient will:

a.

exhibit chronic fatigue.

b.

evidence extreme lethargy at night.

c.

manifest confusion and agitation at night.

d.

be more alert between 6 PM and 11 PM.

ANS: C

When cognitive ability diminishes in the evening, the pattern is called sundown syndrome. Diminished cognitive ability may result in patient disorientation and agitation.

DIF:Cognitive Level: ComprehensionREF:Text Page: 410

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

8. Which intervention would likely be most useful when attempting to prevent or lessen the symptoms associated with sundown syndrome?

a.

Keeping the patients room quiet and dimly lit at night

b.

Interacting frequently with the patient during evening hours

c.

Providing the patient with a large protein-based bedtime snack

d.

Giving the patient a soft stuffed animal to provide a source of security

ANS: B

Sundown syndrome may be associated with having fewer orienting environmental stimuli, such as planned activities, meals, and contact with others. Frequent interactions with staff members will increase stimuli and provide opportunities for reorientation.

DIF:Cognitive Level: ApplicationREF:Text Page: 410

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

9. Which nursing diagnosis would be appropriate for a patient with Alzheimer disease?

a.

Disorientation related to hyperthermia

b.

Anxiety (moderate) related to dementia

c.

Disturbed sensory perception (visual) related to normal aging

d.

Disturbed thought processes related to irreversible brain disorder

ANS: D

The maladaptive cognitive responses of a patient with Alzheimer disease are associated with the presence of neuritic plaques, neurofibrillary tangles, and cortical atrophy.

DIF: Cognitive Level: Comprehension REF: Text Page: 406 | Text Page: 408

TOP:Nursing Process: Diagnosis|Nursing Process: Analysis

MSC:NCLEX: Physiological Integrity: Physiological Adaptation

10. A 45-year-old patient shows marked cognitive impairment that has developed progressively over several months. A family member reports the patients father had early-onset dementia. What research-based information can be given to the family in response to their concerns about the patient developing early-onset dementia?

a.

The risk for developing the condition is about 50% only if both parents were affected.

b.

The greatest risk exists for relatives of individuals diagnosed with Alzheimer disease before age 55 years.

c.

Added risk is present only for people with Down syndrome, so relatives without Down syndrome are essentially safe.

d.

Results of the research on genetic predisposition and its effect on the development of early-onset dementia are still unclear.

ANS: B

The risk for development of Alzheimer disease (AD) is greater for relatives of people with the illness than it is for those with no family history of AD. An individual with one parent with early-onset AD has a 50% chance of developing it before the age of 55 years as well. Those offspring who do not inherit early-onset AD do not pass it on to their own children and presumably have the same risk of developing AD much later in life as does the general population. Down syndrome does appear to be a risk factor for early-onset AD

DIF:Cognitive Level: ApplicationREF:Text Pages: 406-407

TOP:Nursing Process: Implementation

MSC:NCLEX: Physiological Integrity: Physiological Adaptation

11. Family members of a delirious elderly patient are very anxious and express their concerns about placing the patient in a nursing home. What information should serve as a basis for the nurses reply?

a.

Delirium is reversible, and the patient will likely recover.

b.

The symptoms are related to depression, which can be treated.

c.

Delirium usually progresses to dementia, which is usually permanent.

d.

Home care should be attempted; a nursing home should be the last resort.

ANS: A

Delirium is considered a reversible disorder when the cause has been discovered and treated. Most patients who are otherwise healthy can return to their former living arrangements.

DIF:Cognitive Level: ComprehensionREF:Text Pages: 404-405

TOP:Nursing Process: Implementation

MSC:NCLEX: Physiological Integrity: Physiological Adaptation

12. A 72-year-old female patient has delirium secondary to anticholinergic medication toxicity. The nurse planning discharge care teaches the family to be alert for maladaptive cognitive symptoms because:

a.

delirium is a hypersensitivity reaction.

b.

the elderly often deny changes in cognition.

c.

elderly females are more prone to delirium than elderly males.

d.

slower metabolism in the elderly predisposes to medication toxicity.

ANS: D

Slower metabolism and excretion of drugs predispose the elderly to toxic reactions marked by maladaptive cognitive responses. This is particularly true with anticholinergics and benzodiazepines.

DIF:Cognitive Level: ComprehensionREF:Text Pages: 403-404

TOP:Nursing Process: Planning

MSC:NCLEX: Physiological Integrity: Physiological Adaptation

13. A nurse is caring for a patient who is confused, disoriented, and experiencing visual hallucinations. While preparing to provide personal care, the nurse should:

a.

ask the patient, Do you remember who I am?

b.

speak minimally so as not to disturb the patient.

c.

pat the patient on the forearm and say, Lets get started.

d.

explain to the patient what will happen during the care.

ANS: D

In these situations nurses should identify themselves each time they enter the room and give the patient simple explanations and directives. A patient with cognitive impairment cannot be expected to remember the nurse from visit to visit and will respond better to easily comprehended information. The nurse also should be prepared to repeat directions as often as necessary.

DIF:Cognitive Level: ApplicationREF:Text Page: 424

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

14. A patient experiencing delirium secondary to drug toxicity is manifesting paranoid thinking and noisy, assaultive behavior and is currently pacing the room. The nurses initial intervention is to:

a.

prepare to apply supervised restraints.

b.

request an intravenous sedative.

c.

calmly attempt to quiet the patient.

d.

attempt to divert the patients attention.

ANS: C

Restraints may be ordered to protect the delirious patient from self-injury or from injuring others. Initially an attempt should be made to calm the patient by addressing him in a quiet, controlled manner.

DIF:Cognitive Level: ApplicationREF:Text Page: 427

TOP:Nursing Process: Planning

MSC:NCLEX: Safe, Effective Care Environment: Management of Care

15. A patient diagnosed with dementia associated with excessive alcohol use is shown a pencil, a nickel, and a safety pin and asked to repeat the names of each. Later when asked to identify these three items the patient is unable to do so. The nurse assesses this as:

a.

apraxia.

b.

agnosia.

c.

concreteness.

d.

catastrophizing.

ANS: B

Agnosia is difficulty recognizing well-known objects.

DIF:Cognitive Level: ApplicationREF:Text Page: 410

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

16. A patient diagnosed with dementia associated with excessive alcohol use tells a nurse, Last week I had to take my baby to the hospital for major surgery. Thats why Ive been so nervous and needed to come here. The nurse is aware that the patient has never parented any children. The symptom described can be assessed as:

a.

akathisia.

b.

confabulation.

c.

intellectualization.

d.

magical thinking.

ANS: B

Confabulation is the process of making up a response to a question when one cannot remember the answer. It is a face-saving strategy that helps the individual deny memory loss.

DIF:Cognitive Level: ApplicationREF:Text Page: 410

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

17. A person who is the caregiver of a parent with early-to-middle-stage Alzheimer disease is concerned about possible episodes of incontinence. What strategy should the nurse suggest?

a.

Limiting the patients fluid intake to 1000 ml daily

b.

Discussing the use of an indwelling catheter with the health care provider

c.

Putting plastic coverings on the beds, upholstered chairs, and sofas

d.

Taking the patient to the bathroom at least every 2 hours when the patient is awake

ANS: D

This measure will best protect patient dignity and preserve functional status at this time. Limiting fluid intake and the introduction of an indwelling catheter are not justified and could result in physical harm to the patient. While placing plastic protectors on the furniture may help prevent damage, the intervention has no impact on the prevention of incontinence.

DIF:Cognitive Level: ApplicationREF:Text Pages: 423-424

TOP:Nursing Process: Planning

MSC:NCLEX: Physiological Integrity: Basic Care and Comfort

18. A nurse caring for a patient with Alzheimer disease can anticipate that the family will most likely need information about:

a.

antimetabolites.

b.

benzodiazepines.

c.

immunosuppressants.

d.

acetylcholinesterase inhibitors.

ANS: D

Acetylcholinesterase inhibitors are often prescribed to treat Alzheimer disease. These drugs allow greater concentration of acetylcholine in the brain, thereby improving cognitive function.

DIF:Cognitive Level: ComprehensionREF:Text Pages: 424-425

TOP:Nursing Process: Planning

MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

19. A nurse would attempt to reduce nighttime agitation for a patient with either delirium or dementia by:

a.

giving warm milk as a snack at bedtime.

b.

keeping a soft light on in the patients room.

c.

placing a large-faced lighted alarm clock opposite the bed.

d.

hanging family pictures near enough to the bed to be easily seen.

ANS: B

A medium-intensity light will reduce shadows and reduce the agitation that comes with misinterpreted stimuli. A weaker-intensity light, such as the typical nightlight, may produce shadows. The snack may help minimize hunger and induce sleep but will have little effect on agitation, and the clock and family pictures may help with orientation only.

DIF:Cognitive Level: ApplicationREF:Text Page: 426

TOP:Nursing Process: Planning

MSC:NCLEX: Physiological Integrity: Basic Care and Comfort

20. The goal for a patient with disturbed thought processes is, The patient will:

a.

be safe from injury.

b.

meet basic biological needs.

c.

achieve optimum cognitive functioning.

d.

maintain positive interpersonal relationships.

ANS: C

Achieving optimum cognitive functioning relates directly to the problem of disturbed thought processes. The other options make appropriate short-term goals.

DIF:Cognitive Level: ApplicationREF:Text Page: 420

TOP:Nursing Process: Outcome Identification

MSC: NCLEX: Psychosocial Integrity

21. A patient is admitted with a tentative diagnosis of delirium. The patient repeatedly mistakes one of the nursing staff for a family member. The nurse documents that this patient is experiencing a disturbance in which area of functioning?

a.

Consciousness

b.

Attention

c.

Perception

d.

Cognition

ANS: C

The area of perception includes misinterpretations, illusions, and hallucinations. The patient believes that a nurse is a family member, which can be construed to be a misinterpretation of reality or a misperception.

DIF:Cognitive Level: ApplicationREF:Text Page: 405

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

22. An elderly patient with dementia paces the hallway and often wanders. The nurse documents that the patient is exhibiting which type of behavior characteristic of dementia?

a.

Passive behavior

b.

Functionally impaired behavior

c.

Involuntary psychomotor behavior

d.

Nonaggressive psychomotor behavior

ANS: D

Nonaggressive psychomotor behavior includes behaviors characterized by an increase in gross motor movement that does not have a negative effect on others but draws attention because of its repetitive nature. Examples include restlessness, wandering, and pacing.

DIF:Cognitive Level: ComprehensionREF:Text Page: 411

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

23. An adolescent is diagnosed with dementia. The patients age would cause a nurse to suspect an underlying condition associated with a history of:

a.

traumatic brain injury (TBI).

b.

neurosyphilis.

c.

Pick disease.

d.

hypothyroidism.

ANS: A

In the adolescent population, dementia is most likely to be associated with juvenile-type Huntington disease, Wilson disease, subacute sclerosing panencephalitis, AIDS, substance abuse (especially inhalants), and traumatic brain injury (TBI). The other listed disorders are more likely to affect the elderly.

DIF:Cognitive Level: ComprehensionREF:Text Page: 411

TOP:Nursing Process: Assessment

MSC:NCLEX: Physiological Integrity: Physiological Adaptation

24. A nurse is working with a family with an elderly member who is in the prediagnostic phase of Alzheimer disease. The most important nursing intervention at this time would be to provide:

a.

family consultation to facilitate communication.

b.

information about support groups and counseling.

c.

options directed toward the reduction of caregiver stress.

d.

education that helps them understand their situation.

ANS: D

In the prediagnostic phase, families need information that will help them understand their situation. A consultation is conducted at the time of diagnosis. Support groups and counseling are useful during the role-change phase. Options to reduce caregiver stress are helpful during the chronic caregiving phase.

DIF:Cognitive Level: ApplicationREF:Text Page: 428

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

25. A family has noted these behaviors in their elderly parent: periodic indecisiveness, forgetfulness, mild transient confusion, occasional misperception, distractibility, and occasional unclear thinking. Where on the continuum of cognitive responses would this patient be?

Adaptive responses      Maladaptive responses

              1                2                    3

a.

At point 1

b.

At point 2

c.

At point 3

ANS: B

The behaviors noted are neither adaptive nor totally maladaptive.

DIF:Cognitive Level: ApplicationREF:Text Page: 404

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

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