Exam (elaborations)
PN 120 PREPU CHAPTER 24 EXAM
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PN 120 PREPU CHAPTER 24 EXAM...
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PN 120 PREPU CHAPTER 24 EXAMWhich nursing diagnosis would be the priority for the client experiencing acute
delirium? - ANSWER Risk for injury related to confusion and cognitive deficits
Which term is used to describe the inability to execute motor functioning, despite
intact motor abilities? - ANSWER Apraxia
What is the primary sign of delirium? - ANSWER An altered level of
consciousness
An 80-year-old is brought to the clinic by the client's spouse. The client has a
history of peripheral vascular disease and type 2 diabetes. The spouse states that the
client hasn't seemed to be normal for the preceding few days, noting that the client
has been lethargic and mildly confused at times and has been incontinent of urine.
The spouse reports that the client's blood glucose levels have been elevated. The
nurse considers which as the most likely explanation for the client's change in
mental status? - ANSWER Delirium related to underlying medical problem
The client is an 84-year-old suffering from delirium. The client has been in a
nursing home for the past 2 years but recently is becoming combative and has
become a threat to staff. Which medication would the client most likely receive for
these symptoms? - ANSWER Haloperidol
The client is 42 years old, married, and has two children, ages 16 and 18. The client
is also caring for the client's parent, who is in the late stages of Alzheimer's disease.
The nurse would want to assess the client for what? - ANSWER Signs of stress
A client was admitted to an inpatient unit with a diagnosis of dementia. A nursing
assessment and interview of the client would include what? - ANSWER Intellectual
ability, health history, and self-care ability
An 82-year-old client with a diagnosis of vascular dementia has been admitted to
the geriatric psychiatry unit of the hospital. In planning the care of this client,
which outcome should the nurse prioritize? - ANSWER The client will remain free
from injury.
A client diagnosed with Alzheimer's disease has an alteration in language ability.
, This alteration would be documented as what? - ANSWER Aphasia
The nurse is assessing a client who has received a tentative diagnosis of delirium.
The nurse is explaining to the family about the major cause of the client's condition.
Which statement by the nurse would be most appropriate? - ANSWER "The client's
diagnosis is primarily based on the rapid onset of the change in consciousness."
A nurse is assessing a client diagnosed with Alzheimer's disease. As part of the
assessment, the nurse asks the client to identify common objects. The nurse is
assessing for what? - ANSWER Agnosia
A nurse is caring for a client with delirium. The client sees a thermometer on the
nurse's table and shouts, "Don't stab me!" and cowers. Which feature of delirium is
this client exhibiting? - ANSWER Illusion
A client with dementia becomes extremely agitated shortly after being admitted to
the psychiatric unit. The nurse is reluctant to use physical restraints to control the
client. What is a likely reason the nurse has this reluctance? - ANSWER Physical
restraints may increase the client's agitation.
A group of friends have arrived at the hospital to visit a client recently diagnosed
with delirium. The nurse tells the friends they can visit with the client one at a time.
What is the likely reason for the nurse to give this instruction? - ANSWER The
nurse wants to prevent increasing the client's confusion.
The nurse is caring for a client with dementia. The client's brain images show
atrophy of cerebral neurons and enlargement of the third and fourth ventricles.
What is the cause of dementia in this client? - ANSWER Alzheimer's disease
A nurse's aide has rung the call light for assistance while providing a client's
twice-weekly bath because the client became agitated and aggressive while being
undressed. Knowing that the client has a diagnosis of Alzheimer's disease and is
prone to agitation, which measure may help in preventing this client's agitation? -
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