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NR341 COMPLEX ADULT HEALTH EXAM 1 LATEST REAL EXAM QUESTIONS AND CORRECT ANSWERS 2 versions
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NR341 COMPLEX ADULT HEALTH EXAM 1 LATEST REAL EXAM QUESTIONS AND CORRECT ANSWERS 2 versions
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NR341 COMPLEX ADULT HEALTH EXAM 1 LATEST REAL EXAMQUESTIONS AND CORRECT ANSWERS
2 versions
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)
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.)
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 of the following actions
should the nurse take?
A. assist the client to the correct room.
B. place the client in restraints.
C. re-orient the client to time and place.
D. move the client to a room at the end of the hall. - A
(assisting the client to the correct room protects both clients. It helps re-orient the client
who is unable to find her own room, and it prevents the other client from an invasion of
her personal space.)
A nurse in a long-term care facility is caring for a client who has late stage Alzheimer's
disease. Which of the following actions should the nurse include in the plan of care?
A. post a written schedule of daily activities.
B. use an overhead loudspeaker to announce events.
C. provide a consistent daily routine.
D. allow the client to choose free time activities. - C
(A consistent daily routine is appropriate for the care of a client who has Alzheimer's
disease.)
A nurse is monitoring a client who is post operative and unable to respond to questions.
Which of the following nonverbal behaviors should the nurse identify as an indication
that the client has pain? (Select all that apply.)
A. Restlessness
B. Grimacing
C. Moaning
D. Clenching
E. Drowsiness - A, B, D
(Restlessness is correct. Clients who have uncontrolled pain often become restless and
anxious in response to the discomfort.
Grimacing is correct. Facial movements such as grimacing, tightly closing the eyes, and
biting the lower lip are behavioral indicators of pain.
Moaning is incorrect. Moaning, groaning, crying, and screaming are vocalizations, not
nonverbal behaviors, that indicate pain.
Clenching is correct. Clenching the teeth and biting the lower lip are common findings in
clients who have pain.
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