Question 1

An older adult patient in the intensive care unit has visual and auditory illusions.Which intervention will be most helpful?

Accepted Answer

A) Place large clocks and calendars on the wall. 
B) Place personally meaningful objects in view. 
C) Use the patient's glasses and hearing aids. 
D) Keep the room brightly lit at all times. 
A) Place large clocks and calendars on the wall. 
B) Place personally meaningful objects in view. 
C) Use the patient's glasses and hearing aids. 
D) Keep the room brightly lit at all times. C

Question 2

What is the priority nursing diagnosis for a patient with 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 3

A patient with stage 1 Alzheimer's disease tires easily and prefers to stay home rather than attend social activities.The spouse does the grocery shopping because the patient cannot remember what to buy.Which nursing diagnosis applies at this time?

Accepted Answer

A) Risk for injury 
B) Impaired memory 
C) Self-care deficit 
D) Caregiver role strain 
A) Risk for injury 
B) Impaired memory 
C) Self-care deficit 
D) Caregiver role strain B

Question 4

What is the priority need for a patient 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

Question 5

A patient with stage 2 Alzheimer's 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 6

Which assessment findings would the nurse expect in a patient with 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

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.Alzheimer's disease was subsequently diagnosed.Which stage of Alzheimer's 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

A patient with dementia no longer recognizes family members.The family asks how long it will be before their family member recognizes them when they visit.What is the nurse's best reply?

Accepted Answer

A) "Your family member will never again be able to identify you." 
B) "I think that is a question the health care provider should answer." 
C) "One never knows.Consciousness fluctuates in persons with dementia." 
D) "It is disappointing when someone you love no longer recognizes you." 
A) "Your family member will never again be able to identify you." 
B) "I think that is a question the health care provider should answer." 
C) "One never knows.Consciousness fluctuates in persons with dementia." 
D) "It is disappointing when someone you love no longer recognizes you."

Question 9

Which environmental adjustment should the nurse make for a patient with delirium and 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 10

A patient with fluctuating levels of consciousness,disturbed orientation,and perceptual alteration begs,"Someone get the 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 11

A patient with Alzheimer's 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 12

What is the priority intervention for a patient with delirium who has fluctuating levels of consciousness,disturbed orientation,and perceptual alterations?

Accepted Answer

A) Avoidance of physical contact 
B) High level of sensory stimulation 
C) Careful observation and supervision 
D) Application of wrist and ankle restraints 
A) Avoidance of physical contact 
B) High level of sensory stimulation 
C) Careful observation and supervision 
D) Application of wrist and ankle restraints

Question 13

Which intervention is appropriate to use for patients 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 14

An older adult patient takes digoxin and hydrochlorothiazide daily,as well as lorazepam (Ativan)as needed for anxiety.Over 2 days,the patient developed confusion,slurred speech,an unsteady gait,and fluctuating levels of orientation.These findings are most characteristic of:

Accepted Answer

A) delirium 
B) dementia 
C) amnestic syndrome 
D) Alzheimer's disease 
A) delirium 
B) dementia 
C) amnestic syndrome 
D) Alzheimer's disease

Question 15

Consider these problems: apolipoprotein E (apoE)malfunction,neuritic plaques,neurofibrillary tangles,granulovascular degeneration,and brain atrophy.Which condition corresponds to this group?

Accepted Answer

A) Alzheimer's disease 
B) Acquired immunodeficiency syndrome (AIDS)-related dementia 
C) Wernicke's encephalopathy 
D) Central anticholinergic syndrome 
A) Alzheimer's disease 
B) Acquired immunodeficiency syndrome (AIDS)-related dementia 
C) Wernicke's encephalopathy 
D) Central anticholinergic syndrome

Question 16

Consider these health problems: Lewy body disease,Pick's disease,and Korsakoff's 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 17

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.

Question 18

During morning care,a nursing assistant asks a patient 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 19

A patient with 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 20

A patient with Alzheimer's 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 the 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 the 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.

Exam 18: Neurocognitive Disorders

An older adult patient in the intensive care unit has visual and auditory illusions.Which intervention will be most helpful?

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

A patient with stage 1 Alzheimer's disease tires easily and prefers to stay home rather than attend social activities.The spouse does the grocery shopping because the patient cannot remember what to buy.Which nursing diagnosis applies at this time?

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

A patient with stage 2 Alzheimer's 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:

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

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.Alzheimer's disease was subsequently diagnosed.Which stage of Alzheimer's disease is evident?

A patient with dementia no longer recognizes family members.The family asks how long it will be before their family member recognizes them when they visit.What is the nurse's best reply?

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

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

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

What is the priority intervention for a patient with delirium who has fluctuating levels of consciousness,disturbed orientation,and perceptual alterations?

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

An older adult patient takes digoxin and hydrochlorothiazide daily,as well as lorazepam (Ativan)as needed for anxiety.Over 2 days,the patient developed confusion,slurred speech,an unsteady gait,and fluctuating levels of orientation.These findings are most characteristic of:

Consider these problems: apolipoprotein E (apoE)malfunction,neuritic plaques,neurofibrillary tangles,granulovascular degeneration,and brain atrophy.Which condition corresponds to this group?

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

Which description best applies to a hallucination? A patient:

During morning care,a nursing assistant asks a patient 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?

A patient with 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 with Alzheimer's 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.

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

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Anxiety, anxiety Disorders, and Obsessive-Compulsive Disorders

Somatoform Disorders and Dissociative Disorders

Personality Disorders

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Mood Disorders: Depression

Bipolar Spectrum Disorders

Schizophrenia Spectrum Disorders

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Care for the Dying and Those Who Grieve

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