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Chapter 24 PrepU NRS330
Terms in this set (35)
Which nursing diagnosis would be the priority for the client experiencing acute delirium?
Risk for injury related to confusion and cognitive deficits
The nurse documents that a client diagnosed with dementia of the Alzheimer's type is exhibiting agnosia when the client is observed being unable to ...
identify a picture of a car.
What is the primary sign of delirium?
An altered level of consciousness
A client with Alzheimer's disease in the intensive treatment unit repeatedly tries to go into other clients' rooms to nap during the day. The most appropriate nursing intervention for this client is what?
Escorting the client to the client's room for napping
A nurse is studying the medical chart of a client with delirium. The nurse finds that the client was given haloperidol. What would be the most likely reason for administering this drug to the client?
To decrease 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?
The nurse wants to prevent increasing the client's confusion.
When assessing a client with dementia, the nurse notes that the client is having difficulty identifying common items, such as a ball or book. The nurse interprets this finding as what?
A client is diagnosed with Alzheimer's disease. While assessing the client, the nurse notes that the client has trouble identifying objects such as a key and spoon. The nurse would document this as what?
The nurse should consider the intervention referred to as "going along with" when managing the care of which client?
the older widower who is worried about his wife not being able to visit because of the snow
Which client behavior should the nurse attempt to change when managing a client's tendency to wander and pace at night?
take a nap mid afternoon and before dinner
Which term is used to describe the inability to execute motor functioning, despite intact motor abilities?
Which is the primary treatment for delirium?
Identify and treat any causal or contributing medical conditions
A client diagnosed with Alzheimer's disease has an alteration in language ability. This alteration would be documented as what?
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?
"The client's diagnosis is primarily based on the rapid onset of the change in consciousness."
The nurse is assessing the orientation of a client who belongs to the religious group Jehovah's Witnesses. Which questions should the nurse ask this client? Select all that apply.
Where is your workplace located?
Where is your residence located?
What is your mother's name?
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?
A 73-year-old client has been brought to the emergency department by the client's adult children due to abrupt and uncharacteristic changes in behavior, including impairments of memory and judgment. The subsequent history and diagnostic testing have resulted in a diagnosis of delirium. Which teaching point about the client's diagnosis should the nurse provide to the family?
"If the underlying cause of delirium is identified and treated, most people return to their previous level of functioning."
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?
The client will remain free from injury.
When assessing a client with dementia, a nurse identifies that the client is experiencing hallucinations. Based on the nurse's understanding of this disorder, which type of hallucination would the nurse expect as most common?
What is the greatest benefit support groups provide to the caregivers of clients diagnosed with dementia?
provides interaction with those with similar concerns.
The client has early Alzheimer's disease. When asked about family history, the client relates that the client has two children who are both grown and who visit the client around the holidays each year. The nurse subsequently discovers that the client has one child who is currently assigned overseas and who has not been home for 2 years. Which would best describe the client's behavior?
The client is confabulating, most likely to cover for memory deficit.
Delirium can be differentiated from many other cognitive disorders in which way?
It has a rapid onset and is highly treatable if diagnosed quickly.
The nurse preparing an educational program on dementia should include which information?
The onset of symptoms of dementia is gradual
Which medication used to treat dementia requires a liver function test every 1 to 2 weeks?
Which would not be considered a primary goal of nursing care for a client with delirium?
Achievement of self-esteem needs
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?
Delirium related to underlying medical problem
A client was admitted to an inpatient unit with a diagnosis of dementia. A nursing assessment and interview of the client would include what?
Intellectual ability, health history, and self-care ability
A client with a medical diagnosis of dementia of Alzheimer's type has been increasingly agitated in recent days. As a result, the nurse has identified the nursing diagnosis of "risk for injury related to agitation and confusion" and an outcome of "the client will remain free from injury." What intervention should the nurse use in order to facilitate this outcome?
Monitor amount of environmental stimulation and adjust as needed.
A care 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 dementia of Alzheimer's type and is prone to agitation, which measure may help in preventing this client's agitation?
Reminding the client multiple times that he or she will be soon having a bath
A client has vascular neurocognitive disorder. When teaching the family about the cause of this disorder, which would the nurse expect to integrate into the explanation?
Blood flow in the vessels to the brain are blocked.
Which can be identified as a hallmark symptom of dementia?
Short-term memory loss
A 35-year-old client is delirious after being lost in the woods for several days and becoming severely dehydrated. At 9 p.m. the client tells the nurse to get the client's clothes because the client has to get home to the client's family. Which response by the nurse is most therapeutic?
"You're in the hospital. You did not drink for several days, but you're getting better now."
The nurse understands that numerous comorbidities can contribute to the development of dementia. Which client may be at risk for dementia?
A 49-year-old client whose human immunodeficiency virus (HIV) has progressed to acquired immunodeficiency syndrome (AIDS)
In clients with Alzheimer's disease, neurotransmission is reduced, neurons are lost, and the hippocampal neurons degenerate. Which neurotransmitter is most involved in cognitive functioning?
A older adult client develops delirium secondary to an infection. Which would be the most likely cause?
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