NUR325 Exam 1 ASU - ATI, Textbook Questions And Answers, Graded A+
A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium?
A. A client wants to know the current time while there is a clock on the wall.
B...
graded a a nurse is caring for a group of older adult clients which of the following manifestations indicates one of the clients is experien
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NUR325 Exam 1 ASU - ATI, Textbook Questions
And Answers, Graded A+
A nurse is caring for a group of older adult clients. Which of the following
manifestations indicates one of the clients is experiencing delirium?
A. A client wants to know the current time while there is a clock on the wall.
B. A client attempts to climb out of bed and repeatedly states she must get home.
C. A client requests extra blankets when the thermostat in the room indicates 25.6
Degrees C (78 F).
D. A client refuses to get out of bed and has no motivation to attend to daily
hygiene.
B.
(Delirium is characterized by a change in cognition that occurs over a short period of
time. It results from a secondary physiological condition (e.g., infection, surgery,
prolonged hospitalization, hypoxia, fever, medications) and is a transient disorder.
Although delirium can occur with any age, it is more common in older adults. It
frequently progresses in the evening hours and is sometimes called "sundown
syndrome." Delirium is characterized by alterations in memory, agitation, restlessness,
illusions, or hallucinations. A client who becomes acutely confused and agitated may be
showing manifestations of delirium.)
A community health nurse is providing teaching to the family of a client who has
primary dementia. Which of the following manifestations should the nurse tell the
family to expect?
A. Decreased auditory and visual acuity.
B. Decreased display of emotion.
C. Personality traits that are opposite of original traits.
D. Forgetfulness gradually progressing to disorientation.
D.
(Dementia usually appears first as forgetfulness. Other manifestations may be apparent
only upon neurologic examination or cognitive testing. Loss of functioning progresses
slowly from impaired language skills and difficulty with ordinary daily activities to severe
memory loss and complete disorientation with withdrawal from social interaction.)
A nurse is caring for a client who has dementia. When performing a Mental Status
Examination (MSE) the nurse should include which of the following data? (Select
all that apply.)
A. Ability to perform calculations
B. Level of consciousness
C. Recall ability
D. Long-term memory
E. Level of orientation
,A, C, E.
(Evaluating the client's ability to perform calculations is an included component of an
MSE. Determining the client's level of consciousness is not a component of an MSE.
Identifying the client's ability to recall a list of objects or words is an included component
of an MSE. Evaluating long-term memory is not a component of an MSE. Determining
the client's level of orientation is an included component of an MSE.)
A nurse is caring for a client who has dementia due to Alzheimer's disease and
was admitted to a long-term care facility following the death of her partner of 40
years. The client states, " I want to go home; my husband is waiting for me to
cook dinner. "Which of the following responses by the nurse is appropriate?
A. " this is where you live now."
B. " this is a safer place for you to live."
C. "Tell me what you like to cook for dinner."
D. "Your family said there is no one to care for you at home."
C.
(Alzheimer's disease is a progressive cognitive disorder. Dementia due to Alzheimer's
disease means that the client is experiencing the later stages of the illness with
moderately severe to severe cognitive decline. By asking the client to talk about what
she likes to cook for dinner, the nurse is demonstrating validation therapy by asking the
client to talk about the areas that concerned her. The nurse could continue the
conversation by discussing how much the client misses her home and partner.
Validation therapy helps clients who have cognitive disorders discuss their feelings
about past events and people.)
A nurse on a long-term care unit is creating a plan of care for a client who has
Alzheimer's disease. Which of the following interventions should the nurse
include in the plan?
A. rotate assignment of daily caregivers.
B. provide an activity schedule that changes from day to day.
C. limit time for the client to perform activities.
D. talk the client through tasks one step at a time.
D
(The nurse should plan to talk the client through tasks one step at a time to minimize
confusion and promote independence, which will decrease the client's anxiety level.)
A nurse is caring for a client who is cognitively impaired. Which of the following
rooms will provide a therapeutic environment for this client?
A. A room adjacent to the nursing station
B. A room without a window
C. A room with dim lighting
D. A room containing personal belongings
, D
(A room that contains several of the clients personal belongings assists in maintaining
personal identity and provides a therapeutic environment)
The family of an older adult client brings him to the emergency department after
finding him wandering outside. During the initial assessment, the nurse notes
that the client flinches when she palpates his abdomen yet response to questions
only by nodding and smiling. Which of the following factors should the nurse
identify as a likely explanation for the clients behavior?
A. he is hard of hearing
B. pain
C. confusion
D. language barrier
C
(since the client was manifesting signs of confusion before coming to the emergency
department and currently seems unable to understand or respond to speech, the nurse
should determine that the client has confusion)
A nurse is performing a mental status examination (MSE) on a client who has a
new diagnosis of dementia. Which of the following components should the nurse
include? (Select all that apply.)
A. grooming
B. long-term memory
C. support systems
D. affect
E. presence of pain
A, B, D
(Grooming is included in an MSE which consists of appearance, behavior, speech,
mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of
harming self or others. Long-term memory is included in an MSE which consists of
appearance, behavior, speech, and mood, disorders of the form of thought, perceptual
disturbances, cognition, and ideas of harming self or others. Support systems are not
included in an MSE which consists of appearance, behavior, speech, mood, disorders
of the form of thought, perceptual disturbances, cognition, and ideas of harming self or
others. Affect is included in an MSE which consists of appearance, behavior, speech,
and mood, disorders of the form of thought, perceptual disturbances, cognition, and
ideas of harming self or others. The presence of pain is not included in an MSE which
consists of appearance, behavior, speech, mood, disorders of the form of thought,
perceptual disturbances, cognition, and ideas of harming self or others.)
A nurse is caring for a client who has late stage Alzheimer's disease and is
hospitalized for treatment of pneumonia. During the night shift, the client is found
climbing into the bed of another client who becomes upset and frightened. Which
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