Question 1

What is the priority nursing need for a patient diagnosed with late-stage dementia?

Accepted Answer

A)  Promotion of self-care activities 
B)  Meaningful verbal communication 
C)  Maintenance of nutrition and hydration 
D)  Prevention of the patient from wandering 
A)  Promotion of self-care activities 
B)  Meaningful verbal communication 
C)  Maintenance of nutrition and hydration 
D)  Prevention of the patient from wandering C

Question 2

Which description best applies to a hallucination? A patient:

Accepted Answer

A)  looks at shadows on a wall and says, "I see scary faces." 
B)  states, "I feel bugs crawling on my legs and biting me." 
C)  becomes anxious when the nurse leaves his or her bedside. 
D)  tries to hit the nurse when vital signs are taken. 
A)  looks at shadows on a wall and says, "I see scary faces." 
B)  states, "I feel bugs crawling on my legs and biting me." 
C)  becomes anxious when the nurse leaves his or her bedside. 
D)  tries to hit the nurse when vital signs are taken. B

Question 3

What is the priority nursing diagnosis for a patient experiencing fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?

Accepted Answer

A)  Bathing/hygiene self-care deficit related to altered cerebral function as evidenced by confusion and inability to perform personal hygiene tasks 
B)  Risk for injury related to altered cerebral function, misperception of the environment, and unsteady gait 
C)  Disturbed thought processes related to medication intoxication as evidenced by confusion, disorientation, and hallucinations 
D)  Fear related to sensory perceptual alterations as evidenced by hiding from imagined ferocious dogs 
A)  Bathing/hygiene self-care deficit related to altered cerebral function as evidenced by confusion and inability to perform personal hygiene tasks 
B)  Risk for injury related to altered cerebral function, misperception of the environment, and unsteady gait 
C)  Disturbed thought processes related to medication intoxication as evidenced by confusion, disorientation, and hallucinations 
D)  Fear related to sensory perceptual alterations as evidenced by hiding from imagined ferocious dogs B

Question 4

A patient diagnosed with moderate to severe Alzheimer disease has a dressing and grooming self-care deficit. Designate the appropriate interventions to include in the patient's plan of care. (Select all that apply.)

Accepted Answer

A)  Provide clothing with elastic and hook-and-loop closures. 
B)  Label clothing with the patient's name and name of the item. 
C)  Administer antianxiety medication before bathing and dressing. 
D)  Provide necessary items, and direct the patient to proceed independently. 
E)  If the patient resists, use distraction and then try again after a short interval. 
A)  Provide clothing with elastic and hook-and-loop closures. 
B)  Label clothing with the patient's name and name of the item. 
C)  Administer antianxiety medication before bathing and dressing. 
D)  Provide necessary items, and direct the patient to proceed independently. 
E)  If the patient resists, use distraction and then try again after a short interval.

Question 5

Goals and desired outcomes for an older adult patient experiencing delirium caused by fever and dehydration will focus on:

Accepted Answer

A)  returning to premorbid levels of function. 
B)  identifying stressors negatively affecting self. 
C)  demonstrating motor responses to noxious stimuli. 
D)  exerting control over responses to perceptual distortions. 
A)  returning to premorbid levels of function. 
B)  identifying stressors negatively affecting self. 
C)  demonstrating motor responses to noxious stimuli. 
D)  exerting control over responses to perceptual distortions.

Question 6

A hospitalized patient experiencing delirium misinterprets reality and a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? Each patient will:

Accepted Answer

A)  remain safe in the environment. 
B)  participate actively in self-care. 
C)  communicate verbally. 
D)  acknowledge reality. 
A)  remain safe in the environment. 
B)  participate actively in self-care. 
C)  communicate verbally. 
D)  acknowledge reality.

Question 7

An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police took the person home, the spouse reported frequent wandering into neighbors' homes. Which stage of Alzheimer disease is evident?

Accepted Answer

A)  1 (mild) 
B)  2 (moderate) 
C)  3 (moderate to severe) 
D)  4 (late) 
A)  1 (mild) 
B)  2 (moderate) 
C)  3 (moderate to severe) 
D)  4 (late)

Question 8

During morning care, a nursing assistant asks a patient diagnosed with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response?

Accepted Answer

A)  Sundown syndrome 
B)  Confabulation 
C)  Perseveration 
D)  Delirium 
A)  Sundown syndrome 
B)  Confabulation 
C)  Perseveration 
D)  Delirium

Question 9

When used for treatment of patients diagnosed with Alzheimer disease, which medication would be expected to antagonize N-methyl-D-aspartate (NMDA) channels rather than cholinesterase?

Accepted Answer

A)  Donepezil (Aricept) 
B)  Rivastigmine (Exelon) 
C)  Memantine (Namenda) 
D)  Galantamine (Razadyne) 
A)  Donepezil (Aricept) 
B)  Rivastigmine (Exelon) 
C)  Memantine (Namenda) 
D)  Galantamine (Razadyne)

Question 10

An older adult diagnosed with moderate-stage Alzheimer disease forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient's family?

Accepted Answer

A)  Label the bathroom door. 
B)  Take the older adult to the bathroom hourly. 
C)  Place the older adult in disposable adult diapers. 
D)  Make sure the older adult does not eat nonfood items. 
A)  Label the bathroom door. 
B)  Take the older adult to the bathroom hourly. 
C)  Place the older adult in disposable adult diapers. 
D)  Make sure the older adult does not eat nonfood items.

Question 11

Which nursing intervention is appropriate to use for patients diagnosed with either delirium or dementia?

Accepted Answer

A)  Speak in a loud, firm voice. 
B)  Touch the patient before speaking. 
C)  Reintroduce the health care worker at each contact. 
D)  When the patient becomes aggressive, use physical restraint instead of medication. 
A)  Speak in a loud, firm voice. 
B)  Touch the patient before speaking. 
C)  Reintroduce the health care worker at each contact. 
D)  When the patient becomes aggressive, use physical restraint instead of medication.

Question 12

A patient diagnosed with Alzheimer disease wanders at night. Which action should the nurse recommend for a family to use in the home to enhance safety?

Accepted Answer

A)  Place throw rugs on tile or wooden floors. 
B)  Place locks at the tops of doors. 
C)  Encourage daytime napping. 
D)  Obtain a bed with side rails. 
A)  Place throw rugs on tile or wooden floors. 
B)  Place locks at the tops of doors. 
C)  Encourage daytime napping. 
D)  Obtain a bed with side rails.

Question 13

A patient experiencing fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response?

Accepted Answer

A)  "There are no bugs on your legs. Your imagination is playing tricks on you." 
B)  "Try to relax. The crawling sensation will go away sooner if you can relax." 
C)  "Don't worry. I will have someone stay here and brush off the bugs for you." 
D)  "I don't see any bugs, but I know you are frightened so I will stay with you." 
A)  "There are no bugs on your legs. Your imagination is playing tricks on you." 
B)  "Try to relax. The crawling sensation will go away sooner if you can relax." 
C)  "Don't worry. I will have someone stay here and brush off the bugs for you." 
D)  "I don't see any bugs, but I know you are frightened so I will stay with you."

Question 14

Which environmental adjustment should the nurse make for a patient experiencing delirium with perceptual alterations?

Accepted Answer

A)  Keep the patient by the nurse's desk while the patient is awake. Provide rest periods in a room with a television on. 
B)  Light the room brightly, day and night. Awaken the patient hourly to assess mental status. 
C)  Maintain soft lighting day and night. Keep a radio on low volume continuously. 
D)  Provide a well-lit room without glare or shadows. Limit noise and stimulation. 
A)  Keep the patient by the nurse's desk while the patient is awake. Provide rest periods in a room with a television on. 
B)  Light the room brightly, day and night. Awaken the patient hourly to assess mental status. 
C)  Maintain soft lighting day and night. Keep a radio on low volume continuously. 
D)  Provide a well-lit room without glare or shadows. Limit noise and stimulation.

Question 15

An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident?

Accepted Answer

A)  Aphasia 
B)  Apraxia 
C)  Agnosia 
D)  Memory impairment 
A)  Aphasia 
B)  Apraxia 
C)  Agnosia 
D)  Memory impairment

Question 16

A patient experiencing fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs! Get them off!" Which problem is the patient experiencing?

Accepted Answer

A)  Aphasia 
B)  Dystonia 
C)  Tactile hallucinations 
D)  Mnemonic disturbance 
A)  Aphasia 
B)  Dystonia 
C)  Tactile hallucinations 
D)  Mnemonic disturbance

Question 17

A patient diagnosed with stage 2 moderate Alzheimer disease calls the police saying, "An intruder is in my home." Police investigate and discover the patient misinterpreted a reflection in the mirror as an intruder. This phenomenon can be assessed as:

Accepted Answer

A)  hyperorality. 
B)  aphasia. 
C)  apraxia. 
D)  agnosia. 
A)  hyperorality. 
B)  aphasia. 
C)  apraxia. 
D)  agnosia.

Question 18

Consider these health problems: Lewy body disease, Pick disease, and Korsakoff syndrome. Which term unifies these problems?

Accepted Answer

A)  Intoxication 
B)  Dementia 
C)  Delirium 
D)  Amnesia 
A)  Intoxication 
B)  Dementia 
C)  Delirium 
D)  Amnesia

Question 19

A patient has progressive memory deficit associated with dementia. Which nursing intervention would best help the individual function in the environment?

Accepted Answer

A)  Assist the patient to perform simple tasks by giving step-by-step directions. 
B)  Reduce frustration by performing activities of daily living for the patient. 
C)  Stimulate intellectual function by discussing new topics with the patient. 
D)  Promote the use of the patient's sense of humor by telling jokes. 
A)  Assist the patient to perform simple tasks by giving step-by-step directions. 
B)  Reduce frustration by performing activities of daily living for the patient. 
C)  Stimulate intellectual function by discussing new topics with the patient. 
D)  Promote the use of the patient's sense of humor by telling jokes.

Question 20

Which assessment findings would the nurse expect in a patient experiencing delirium? (Select all that apply.)

Accepted Answer

A)  Impaired level of consciousness 
B)  Disorientation to place and time 
C)  Wandering attention 
D)  Apathy 
E)  Agnosia 
A)  Impaired level of consciousness 
B)  Disorientation to place and time 
C)  Wandering attention 
D)  Apathy 
E)  Agnosia

Exam 18: Neurocognitive Disorders

What is the priority nursing need for a patient diagnosed with late-stage dementia?

Which description best applies to a hallucination? A patient:

What is the priority nursing diagnosis for a patient experiencing fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?

A patient diagnosed with moderate to severe Alzheimer disease has a dressing and grooming self-care deficit. Designate the appropriate interventions to include in the patient's plan of care. (Select all that apply.)

Goals and desired outcomes for an older adult patient experiencing delirium caused by fever and dehydration will focus on:

A hospitalized patient experiencing delirium misinterprets reality and a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? Each patient will:

An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police took the person home, the spouse reported frequent wandering into neighbors' homes. Which stage of Alzheimer disease is evident?

During morning care, a nursing assistant asks a patient diagnosed with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response?

When used for treatment of patients diagnosed with Alzheimer disease, which medication would be expected to antagonize N-methyl-D-aspartate (NMDA) channels rather than cholinesterase?

An older adult diagnosed with moderate-stage Alzheimer disease forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient's family?

Which nursing intervention is appropriate to use for patients diagnosed with either delirium or dementia?

A patient diagnosed with Alzheimer disease wanders at night. Which action should the nurse recommend for a family to use in the home to enhance safety?

A patient experiencing fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response?

Which environmental adjustment should the nurse make for a patient experiencing delirium with perceptual alterations?

An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident?

A patient experiencing fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs! Get them off!" Which problem is the patient experiencing?

A patient diagnosed with stage 2 moderate Alzheimer disease calls the police saying, "An intruder is in my home." Police investigate and discover the patient misinterpreted a reflection in the mirror as an intruder. This phenomenon can be assessed as:

Consider these health problems: Lewy body disease, Pick disease, and Korsakoff syndrome. Which term unifies these problems?

A patient has progressive memory deficit associated with dementia. Which nursing intervention would best help the individual function in the environment?

Which assessment findings would the nurse expect in a patient experiencing delirium? (Select all that apply.)

Practicing the Science and Art of Psychiatric Nursing

Mental Health and Mental Illness

Theories and Therapies

Biological Basis for Understanding Psychopharmacology

Settings for Psychiatric Care

Legal and Ethical Basis for Practice

Nursing Process and QSEN: The Foundation for Safe and Effective Care

Communication Skills: Medium for All Nursing Practice

Therapeutic Relationships and the Clinical Interview

Trauma and Stress-Related Disorders

Anxiety, Anxiety Disorders, and Obsessive-Compulsive and Related Disorders

Somatic Symptom Disorders and Dissociative Disorders

Personality Disorders

Eating Disorders

Mood Disorders: Depression

Bipolar Spectrum Disorders

Schizophrenia Spectrum Disorders and Other Psychotic Disorders

Substance-Related and Addictive Disorders

Crisis and Mass Disaster

Child, Partner, and Elder Violence

Sexual Violence

Suicidal Thoughts and Behavior

Anger, Aggression, and Violence

Care for the Dying and Those Who Grieve

Children and Adolescents

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