Nursing A Concept Based Approach to Learning Volume II 2nd Edition-Test Bank
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Nursing: A Concept-Based Approach to Learning, 2e (Pearson)
Module 23 Cognition
The Concept of Cognition
1) The family of an 82-year-old client is concerned about the
changes in the client’s behavior. The client used to be a wonderful cook but
now cannot even remember how to use a blender. For which causes of impaired
cognitive function should the nurse assess the client?
Select all that apply.
1. A) Obesity
2. B)
Nutritional deficiencies
3. C)
Medication reactions
4. D)
Stroke
5. E)
Snoring
Answer: B, C, D
Explanation: A) Any change or deviation from normal in an
individual’s cognitive function should be evaluated. Nutritional deficiencies,
medication reactions, and stroke are conditions that can result in impaired
cognitive ability. Snoring and obesity are not conditions noted to result in
impaired cognitive functioning.
1. B)
Any change or deviation from normal in an individual’s cognitive function should
be evaluated. Nutritional deficiencies, medication reactions, and stroke are
conditions that can result in impaired cognitive ability. Snoring and obesity
are not conditions noted to result in impaired cognitive functioning.
2. C)
Any change or deviation from normal in an individual’s cognitive function
should be evaluated. Nutritional deficiencies, medication reactions, and stroke
are conditions that can result in impaired cognitive ability. Snoring and
obesity are not conditions noted to result in impaired cognitive functioning.
3. D)
Any change or deviation from normal in an individual’s cognitive function
should be evaluated. Nutritional deficiencies, medication reactions, and stroke
are conditions that can result in impaired cognitive ability. Snoring and obesity
are not conditions noted to result in impaired cognitive functioning.
4. E)
Any change or deviation from normal in an individual’s cognitive function
should be evaluated. Nutritional deficiencies, medication reactions, and stroke
are conditions that can result in impaired cognitive ability. Snoring and
obesity are not conditions noted to result in impaired cognitive functioning.
Page Ref: 1578
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Nursing Process: Assessment
Learning Outcome: 1. Summarize the physiology of the
neurological system in relationship to cognition.
2) An older client with no history of cognitive impairment is
showing signs of increased confusion. Which health problem should the nurse
suspect is causing this client’s confusion?
1. A)
Cataracts
2. B)
Hypertension
3. C)
Urinary tract infection
4. D)
Lower back strain
Answer: C
Explanation: A) A new disorder such as an infection can
increase confusion in the older client. Hypertension, lower back strain, and
cataracts are not conditions that are known to cause signs of confusion in
older adults.
1. B) A
new disorder such as an infection can increase confusion in the older client.
Hypertension, lower back strain, and cataracts are not conditions that are
known to cause signs of confusion in older adults.
2. C) A
new disorder such as an infection can increase confusion in the older client.
Hypertension, lower back strain, and cataracts are not conditions that are
known to cause signs of confusion in older adults.
3. D) A
new disorder such as an infection can increase confusion in the older client.
Hypertension, lower back strain, and cataracts are not conditions that are
known to cause signs of confusion in older adults.
Page Ref: 1578
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Summarize the physiology of the
neurological system in relationship to cognition.
3) An older client complains of periods of confusion and
forgetfulness, but reports clear thought process at most times of the day. What
is the an appropriate response of the nurse?
1. A)
“Are you having trouble hearing?”
2. B)
“You probably have nothing to worry about. It’s most likely stress-related.”
3. C)
“Everybody has a few problems with memory as they get older.”
4. D)
“You should probably have an MRI of your brain.”
Answer: A
Explanation: A) People who cannot hear or see well often
appear confused. The nurse should assess whether the client is having
difficulty with these prior to moving on in the assessment process. A nurse
should never discount the client’s concerns, and memory loss with confusion and
forgetfulness is not part of the normal aging process. The nurse needs to
explore further before an expensive diagnostic study is considered. It would be
beyond the scope of practice for the nurse to recommend this testing.
1. B)
People who cannot hear or see well often appear confused. The nurse should
assess whether the client is having difficulty with these prior to moving on in
the assessment process. A nurse should never discount the client’s concerns,
and memory loss with confusion and forgetfulness is not part of the normal
aging process. The nurse needs to explore further before an expensive
diagnostic study is considered. It would be beyond the scope of practice for
the nurse to recommend this testing.
2. C)
People who cannot hear or see well often appear confused. The nurse should
assess whether the client is having difficulty with these prior to moving on in
the assessment process. A nurse should never discount the client’s concerns,
and memory loss with confusion and forgetfulness is not part of the normal
aging process. The nurse needs to explore further before an expensive
diagnostic study is considered. It would be beyond the scope of practice for
the nurse to recommend this testing.
3. D)
People who cannot hear or see well often appear confused. The nurse should
assess whether the client is having difficulty with these prior to moving on in
the assessment process. A nurse should never discount the client’s concerns,
and memory loss with confusion and forgetfulness is not part of the normal
aging process. The nurse needs to explore further before an expensive
diagnostic study is considered. It would be beyond the scope of practice for
the nurse to recommend this testing.
Page Ref: 1578
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 2. Examine the relationship between
cognition and other concepts/systems.
4) The nurse is working with a group of parents of children with
intellectual disabilities. What should the nurse recommend to support
environmental safety for these children?
Select all that apply.
1. A)
Have parents maintain a regular schedule for activities.
2. B)
Teach emotional safety.
3. C)
Use medications to decrease agitation.
4. D)
Provide aids to assist with orientation.
5. E)
Turn the temperature down on the hot water heater.
Answer: B, E
Explanation: A) Turning the temperature down on the hot
water heater will help to prevent accidental burns when bathing or washing
dishes. Teaching emotional safety can decrease the risk of physical or sexual
abuse. Using therapeutic measures to decrease agitation is recommended for
clients with high risk for other-directed violence. Although a routine daily
schedule and orientation aids will structure the client’s environment to
promote optimal orientation, they will not necessarily improve environmental
safety.
1. B)
Turning the temperature down on the hot water heater will help to prevent accidental
burns when bathing or washing dishes. Teaching emotional safety can decrease
the risk of physical or sexual abuse. Using therapeutic measures to decrease
agitation is recommended for clients with high risk for other-directed
violence. Although a routine daily schedule and orientation aids will structure
the client’s environment to promote optimal orientation, they will not
necessarily improve environmental safety.
2. C)
Turning the temperature down on the hot water heater will help to prevent
accidental burns when bathing or washing dishes. Teaching emotional safety can
decrease the risk of physical or sexual abuse. Using therapeutic measures to
decrease agitation is recommended for clients with high risk for other-directed
violence. Although a routine daily schedule and orientation aids will structure
the client’s environment to promote optimal orientation, they will not
necessarily improve environmental safety.
3. D)
Turning the temperature down on the hot water heater will help to prevent
accidental burns when bathing or washing dishes. Teaching emotional safety can
decrease the risk of physical or sexual abuse. Using therapeutic measures to
decrease agitation is recommended for clients with high risk for other-directed
violence. Although a routine daily schedule and orientation aids will structure
the client’s environment to promote optimal orientation, they will not
necessarily improve environmental safety.
4. E)
Turning the temperature down on the hot water heater will help to prevent
accidental burns when bathing or washing dishes. Teaching emotional safety can
decrease the risk of physical or sexual abuse. Using therapeutic measures to
decrease agitation is recommended for clients with high risk for other-directed
violence. Although a routine daily schedule and orientation aids will structure
the client’s environment to promote optimal orientation, they will not
necessarily improve environmental safety.
Page Ref: 1575
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Nursing Process: Implementation
Learning Outcome: 3. Identify commonly occurring
alterations in cognition and their related therapies.
5) A nurse is preparing an educational program for clients in a
long-term care facility regarding methods for coping with age-associated
cognitive changes. Which information should the nurse include?
Select all that apply.
1. A)
Becoming involved in activities such as reading that keep the mind active
2. B)
Playing board games
3. C)
Using assistive devices such as a pill box for medications
4. D)
Making lists, posting appointments on calendars, and writing notes to self
5. E)
Not relying on habits; challenging your mind to remember new things
Answer: A, C, D
Explanation: A) Methods for coping with age-associated
cognitive changes include making lists, playing computer and board games,
keeping your mind active, using assistive devices, and relying on habits to
reduce the chances of forgetting vital information. Challenging your mind to
remember new things is not a technique used for coping with age-associated
cognitive changes.
1. B)
Methods for coping with age-associated cognitive changes include making lists,
playing computer and board games, keeping your mind active, using assistive
devices, and relying on habits to reduce the chances of forgetting vital
information. Challenging your mind to remember new things is not a technique
used for coping with age-associated cognitive changes.
2. C)
Methods for coping with age-associated cognitive changes include making lists,
playing computer and board games, keeping your mind active, using assistive
devices, and relying on habits to reduce the chances of forgetting vital
information. Challenging your mind to remember new things is not a technique
used for coping with age-associated cognitive changes.
3. D)
Methods for coping with age-associated cognitive changes include making lists,
playing computer and board games, keeping your mind active, using assistive
devices, and relying on habits to reduce the chances of forgetting vital
information. Challenging your mind to remember new things is not a technique
used for coping with age-associated cognitive changes.
4. E)
Methods for coping with age-associated cognitive changes include making lists,
playing computer and board games, keeping your mind active, using assistive
devices, and relying on habits to reduce the chances of forgetting vital
information. Challenging your mind to remember new things is not a technique
used for coping with age-associated cognitive changes.
Page Ref: 1578
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 3. Identify commonly occurring
alterations in cognition and their related therapies.
6) The nurse is assessing an older adult client and observes
that the client is having several cognitive problems, including memory and
attention deficits and fluctuating levels of orientation. The nurse confirms
with the family that the client’s symptoms developed over a several-year
period. Which health problem is the client most likely experiencing?
1. A)
Depression
2. B)
Dementia
3. C)
Intellectual disability
4. D)
Delirium
Answer: B
Explanation: A) Dementia is a chronic progressive disorder
characterized by memory impairments that develop slowly over a longer period of
time. Depression is a mood disorder that is characterized by a dysphoric mood
or loss of interest in usual activities. Delirium is an acute, abrupt-onset
condition characterized by prominent disorientation, impaired attention, and
memory deficits. Intellectual disability is defined as significant limitation
in intellectual functioning and adaptive behaviors that occurs before the age
of 18.
18. B)
Dementia is a chronic progressive disorder characterized by memory impairments
that develop slowly over a longer period of time. Depression is a mood disorder
that is characterized by a dysphoric mood or loss of interest in usual
activities. Delirium is an acute, abrupt-onset condition characterized by
prominent disorientation, impaired attention, and memory deficits. Intellectual
disability is defined as significant limitation in intellectual functioning and
adaptive behaviors that occurs before the age of 18.
19. C)
Dementia is a chronic progressive disorder characterized by memory impairments
that develop slowly over a longer period of time. Depression is a mood disorder
that is characterized by a dysphoric mood or loss of interest in usual
activities. Delirium is an acute, abrupt-onset condition characterized by
prominent disorientation, impaired attention, and memory deficits. Intellectual
disability is defined as significant limitation in intellectual functioning and
adaptive behaviors that occurs before the age of 18.
20. D)
Dementia is a chronic progressive disorder characterized by memory impairments
that develop slowly over a longer period of time. Depression is a mood disorder
that is characterized by a dysphoric mood or loss of interest in usual
activities. Delirium is an acute, abrupt-onset condition characterized by
prominent disorientation, impaired attention, and memory deficits. Intellectual
disability is defined as significant limitation in intellectual functioning and
adaptive behaviors that occurs before the age of 18.
Page Ref: 1584
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Nursing Process: Assessment
Learning Outcome: 4. Differentiate common assessment
procedures used to examine cognitive function across the life span.
7) A 70-year-old client comes into the clinic for his pneumonia
vaccine. During the client interview, he seems to have mild difficulty with
several words and has problems remembering the nurse’s name. He is alert and
oriented to time, person, and place. His responses seem appropriate. How should
the nurse describe this client’s cognitive changes?
1. A)
Memory impairment that may be related to cerebral ischemia
2. B)
Normal signs of aging
3. C)
Indicators of depression in the elderly
4. D)
Early symptoms of dementia
Answer: B
Explanation: A) Cognitive changes vary widely in older
adults; however, most older people will not suffer significant memory
impairment. Many may experience mild problems with word finding and remembering
names. The changes described for this client are normal signs of aging and not
symptoms of dementia, depression, or ischemia. Dementia may present with
additional symptoms of memory loss related to orientation and completing
day-to-day tasks. Depression would show signs of flat affect, or withdrawal,
and ischemia may show additional neurological deficits.
1. B)
Cognitive changes vary widely in older adults; however, most older people will
not suffer significant memory impairment. Many may experience mild problems
with word finding and remembering names. The changes described for this client
are normal signs of aging and not symptoms of dementia, depression, or
ischemia. Dementia may present with additional symptoms of memory loss related
to orientation and completing day-to-day tasks. Depression would show signs of
flat affect, or withdrawal, and ischemia may show additional neurological
deficits.
2. C)
Cognitive changes vary widely in older adults; however, most older people will
not suffer significant memory impairment. Many may experience mild problems
with word finding and remembering names. The changes described for this client
are normal signs of aging and not symptoms of dementia, depression, or
ischemia. Dementia may present with additional symptoms of memory loss related
to orientation and completing day-to-day tasks. Depression would show signs of
flat affect, or withdrawal, and ischemia may show additional neurological
deficits.
3. D)
Cognitive changes vary widely in older adults; however, most older people will
not suffer significant memory impairment. Many may experience mild problems
with word finding and remembering names. The changes described for this client
are normal signs of aging and not symptoms of dementia, depression, or
ischemia. Dementia may present with additional symptoms of memory loss related
to orientation and completing day-to-day tasks. Depression would show signs of
flat affect, or withdrawal, and ischemia may show additional neurological
deficits.
Page Ref: 1577
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 4. Differentiate common assessment
procedures used to examine cognitive function across the life span.
8) A client is admitted with signs and symptoms of early
Alzheimer disease. What would be used to confirm this client’s diagnosis?
1. A)
Abnormal CT scan findings of neuritic plaques and tangles in the brain
2. B)
Client history and physical examination
3. C)
Positive blood tests for beta-amyloid and tau proteins
4. D)
Blood test for amyloid plaques and neurofibrillary tangles
Answer: B
Explanation: A) The diagnosis of Alzheimer disease is
based on the client history and physical examination. There is currently is no
one test or procedure that makes the diagnosis of Alzheimer disease. Changes in
the brain with Alzheimer disease include neuritic plaques containing
beta-amyloid protein and neurofibrillary tangles containing tau protein, but
these changes are found at autopsy, not by a CT scan or blood test.
1. B)
The diagnosis of Alzheimer disease is based on the client history and physical
examination. There is currently is no one test or procedure that makes the
diagnosis of Alzheimer disease. Changes in the brain with Alzheimer disease
include neuritic plaques containing beta-amyloid protein and neurofibrillary
tangles containing tau protein, but these changes are found at autopsy, not by
a CT scan or blood test.
2. C)
The diagnosis of Alzheimer disease is based on the client history and physical
examination. There is currently is no one test or procedure that makes the
diagnosis of Alzheimer disease. Changes in the brain with Alzheimer disease
include neuritic plaques containing beta-amyloid protein and neurofibrillary
tangles containing tau protein, but these changes are found at autopsy, not by
a CT scan or blood test.
3. D)
The diagnosis of Alzheimer disease is based on the client history and physical
examination. There is currently is no one test or procedure that makes the
diagnosis of Alzheimer disease. Changes in the brain with Alzheimer disease
include neuritic plaques containing beta-amyloid protein and neurofibrillary
tangles containing tau protein, but these changes are found at autopsy, not by
a CT scan or blood test.
Page Ref: 1585
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 5. Describe diagnostic and laboratory
tests to determine the individual’s cognitive status.
9) The nurse is teaching the family of a client who has just
been diagnosed with dementia. The family asks what treatments are available
that will cure the client. What would be the nurse’s best response to the
family?
1. A)
“There are no treatments that will cure dementia.”
2. B)
“Treatments to cure dementia include the use of vitamin E.”
3. C)
“Treatments to cure dementia involve hormone replacement therapy.”
4. D)
“Treatments to cure dementia include the daily use of ginkgo biloba.”
Answer: A
Explanation: A) Currently no treatment has been found to
reverse or stop the pathological process in progressive dementia. Studies done
on the effect of estrogen in postmenopausal women, vitamin E, and ginkgo biloba
extract have shown some positive results in delaying the progress, but nothing
has proved conclusively to reverse or stop progressive dementia.
1. B)
Currently no treatment has been found to reverse or stop the pathological
process in progressive dementia. Studies done on the effect of estrogen in postmenopausal
women, vitamin E, and ginkgo biloba extract have shown some positive results in
delaying the progress, but nothing has proved conclusively to reverse or stop
progressive dementia.
2. C)
Currently no treatment has been found to reverse or stop the pathological
process in progressive dementia. Studies done on the effect of estrogen in
postmenopausal women, vitamin E, and ginkgo biloba extract have shown some
positive results in delaying the progress, but nothing has proved conclusively
to reverse or stop progressive dementia.
3. D)
Currently no treatment has been found to reverse or stop the pathological
process in progressive dementia. Studies done on the effect of estrogen in
postmenopausal women, vitamin E, and ginkgo biloba extract have shown some positive
results in delaying the progress, but nothing has proved conclusively to
reverse or stop progressive dementia.
Page Ref: 1584
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 6. Explain management of alterations in
cognition and prevention of cognitive dysfunction.
10) While assessing the cognitive status of a 7-year-old child,
the nurse notes that the child was unable to perform division problems and
unable to name several former presidents of the United States. Prior to
determining that this client has cognitive issues, what should the nurse keep
in mind?
1. A)
The child’s developmental level
2. B)
The child’s home environment
3. C)
The child’s nutritional status
4. D)
The parent’s participation in the child’s cognitive development
Answer: A
Explanation: A) The nurse must consider a pediatric
client’s level of cognitive development before asking questions that involve
calculation, judgment, or abstract thought. Even children with normal cognition
will be unable to respond appropriately if they have not yet achieved the level
of development necessary for these activities. The child’s home environment,
nutrition, and parental involvement in cognitive development will not explain
why the child is unable to correctly respond to questions having to do with
complicated math or history.
1. B)
The nurse must consider a pediatric client’s level of cognitive development
before asking questions that involve calculation, judgment, or abstract thought.
Even children with normal cognition will be unable to respond appropriately if
they have not yet achieved the level of development necessary for these
activities. The child’s home environment, nutrition, and parental involvement
in cognitive development will not explain why the child is unable to correctly
respond to questions having to do with complicated math or history.
2. C)
The nurse must consider a pediatric client’s level of cognitive development
before asking questions that involve calculation, judgment, or abstract
thought. Even children with normal cognition will be unable to respond
appropriately if they have not yet achieved the level of development necessary
for these activities. The child’s home environment, nutrition, and parental
involvement in cognitive development will not explain why the child is unable
to correctly respond to questions having to do with complicated math or
history.
3. D)
The nurse must consider a pediatric client’s level of cognitive development
before asking questions that involve calculation, judgment, or abstract
thought. Even children with normal cognition will be unable to respond
appropriately if they have not yet achieved the level of development necessary
for these activities. The child’s home environment, nutrition, and parental
involvement in cognitive development will not explain why the child is unable
to correctly respond to questions having to do with complicated math or
history.
Page Ref: 1576
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Nursing Process: Assessment
Learning Outcome: 7. Demonstrate the nursing process in
providing culturally competent and caring interventions across the life span
for individuals with common alterations in cognition.
11) A client with dementia is prescribed donepezil (Aricept).
What would be important for the nurse to recall about this medication?
1. A)
Donepezil shortens the early stages of Alzheimer disease.
2. B)
Donepezil is a cholinesterase inhibitor and has been known to have positive
effects when used in the early stage of Alzheimer disease.
3. C)
Donepezil is an anticholinergic and has been known to eradicate some of the
symptoms associated with Alzheimer disease.
4. D)
Donepezil should be taken on an empty stomach.
Answer: B
Explanation: A) The cholinesterase inhibitor medications,
such as donepezil and galantamine, have produced positive effects when used in
the early stages of Alzheimer disease. Symptoms are not eradicated but
progression is slowed, and the length of the early stage is extended. These
medications should be taken on a full stomach, and antiemetic medications may
also be needed.
1. B)
The cholinesterase inhibitor medications, such as donepezil and galantamine,
have produced positive effects when used in the early stages of Alzheimer disease.
Symptoms are not eradicated but progression is slowed, and the length of the
early stage is extended. These medications should be taken on a full stomach,
and antiemetic medications may also be needed.
2. C)
The cholinesterase inhibitor medications, such as donepezil and galantamine,
have produced positive effects when used in the early stages of Alzheimer
disease. Symptoms are not eradicated but progression is slowed, and the length
of the early stage is extended. These medications should be taken on a full
stomach, and antiemetic medications may also be needed.
3. D)
The cholinesterase inhibitor medications, such as donepezil and galantamine,
have produced positive effects when used in the early stages of Alzheimer
disease. Symptoms are not eradicated but progression is slowed, and the length
of the early stage is extended. These medications should be taken on a full
stomach, and antiemetic medications may also be needed.
Page Ref: 1592
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 8. Compare and contrast common
independent and collaborative interventions for clients with alterations in
cognitive function.
12) A nursing instructor is teaching a group of student nurses
about the different theories of cognition. Which cognitive development theory
proposes that all children progress through the same stages of development?
1. A)
Piaget
2. B)
Vygotsky
3. C)
Information-processing
4. D)
Erickson
Answer: A
Explanation: A) Piaget’s cognitive development theory
proposes that all children progress through the same stages of development.
Vygotsky’s theory, on the other hand, discards the idea that all children
progress through the same stages of development. Instead, Vygotsky theorized
that skill development is influenced by the child’s environment and culture.
The information-processing theory views the mind as a computer that is always
changing and evolving and takes in information, operates on it, and converts it
to answers. Erickson’s theory is not a cognitive development theory, but rather
is a behavioral development theory.
1. B)
Piaget’s cognitive development theory proposes that all children progress
through the same stages of development. Vygotsky’s theory, on the other hand,
discards the idea that all children progress through the same stages of
development. Instead, Vygotsky theorized that skill development is influenced
by the child’s environment and culture. The information-processing theory views
the mind as a computer that is always changing and evolving and takes in
information, operates on it, and converts it to answers. Erickson’s theory is
not a cognitive development theory, but rather is a behavioral development
theory.
2. C)
Piaget’s cognitive development theory proposes that all children progress
through the same stages of development. Vygotsky’s theory, on the other hand,
discards the idea that all children progress through the same stages of
development. Instead, Vygotsky theorized that skill development is influenced
by the child’s environment and culture. The information-processing theory views
the mind as a computer that is always changing and evolving and takes in
information, operates on it, and converts it to answers. Erickson’s theory is
not a cognitive development theory, but rather is a behavioral development
theory.
3. D)
Piaget’s cognitive development theory proposes that all children progress
through the same stages of development. Vygotsky’s theory, on the other hand,
discards the idea that all children progress through the same stages of
development. Instead, Vygotsky theorized that skill development is influenced
by the child’s environment and culture. The information-processing theory views
the mind as a computer that is always changing and evolving and takes in
information, operates on it, and converts it to answers. Erickson’s theory is
not a cognitive development theory, but rather is a behavioral development
theory.
Page Ref: 1576
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Nursing Process: Assessment
Learning Outcome: 2. Examine the relationship between
cognition and other concepts/systems.
13) A nurse is caring for an older adult who displays symptoms
of cognitive decline. What is true regarding the aging process and cognition?
Select all that apply.
1. A)
Generally, older adults’ short-term memory changes significantly.
2. B)
Generally, many older adults have increased difficulty finding and rapidly
listing words.
3. C)
The ability to use and understand word combinations declines steadily with age.
4. D)
The ability to acquire practical information declines steadily with age.
5. E)
The ability to engage in abstract thought declines slightly.
Answer: B, E
Explanation: A) As adults age, many have increased
difficulty finding and rapidly listing words. Also, the ability to engage in
abstract thought declines slightly. However, in general, older adults’
short-term memory remains intact and the ability to use and understand word
combinations remains intact as well. Most older adults are able to acquire
practical information until their death.
1. B) As
adults age, many have increased difficulty finding and rapidly listing words.
Also, the ability to engage in abstract thought declines slightly. However, in
general, older adults’ short-term memory remains intact and the ability to use
and understand word combinations remains intact as well. Most older adults are
able to acquire practical information until their death.
2. C) As
adults age, many have increased difficulty finding and rapidly listing words.
Also, the ability to engage in abstract thought declines slightly. However, in
general, older adults’ short-term memory remains intact and the ability to use
and understand word combinations remains intact as well. Most older adults are
able to acquire practical information until their death.
3. D) As
adults age, many have increased difficulty finding and rapidly listing words.
Also, the ability to engage in abstract thought declines slightly. However, in
general, older adults’ short-term memory remains intact and the ability to use
and understand word combinations remains intact as well. Most older adults are
able to acquire practical information until their death.
4. E) As
adults age, many have increased difficulty finding and rapidly listing words.
Also, the ability to engage in abstract thought declines slightly. However, in
general, older adults’ short-term memory remains intact and the ability to use
and understand word combinations remains intact as well. Most older adults are
able to acquire practical information until their death.
Page Ref: 1577
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Nursing Process: Assessment
Learning Outcome: 7. Demonstrate the nursing process in
providing culturally competent and caring interventions across the life span
for individuals with common alterations in cognition.
14) A student nurse is learning about the physiology of the
nervous system and its relationship to cognition. What structure plays a role
in memory formation?
1. A)
Neuron
2. B)
Hippocampus
3. C)
Cerebrum
4. D)
Neurotransmitter
Answer: B
Explanation: A) The structure that plays a role in memory
is the hippocampus, located in the limbic system of the brain. A neuron carries
and processes information within the nervous system. The cerebrum is the
largest region of the brain. A neurotransmitter is a chemical messenger within
the nervous system.
1. B)
The structure that plays a role in memory is the hippocampus, located in the
limbic system of the brain. A neuron carries and processes information within
the nervous system. The cerebrum is the largest region of the brain. A
neurotransmitter is a chemical messenger within the nervous system.
2. C)
The structure that plays a role in memory is the hippocampus, located in the
limbic system of the brain. A neuron carries and processes information within
the nervous system. The cerebrum is the largest region of the brain. A
neurotransmitter is a chemical messenger within the nervous system.
3. D)
The structure that plays a role in memory is the hippocampus, located in the
limbic system of the brain. A neuron carries and processes information within
the nervous system. The cerebrum is the largest region of the brain. A
neurotransmitter is a chemical messenger within the nervous system.
Page Ref: 1576
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Summarize the physiology of the
neurological system in relationship to cognition.
Exemplar 23.1 Alzheimer Disease
1) The spouse of a client with Alzheimer disease does not
understand why the client developed the disorder because no one else in the
family has the health problem. What would be the nurse’s best response to the
spouse?
1. A)
“Alzheimer disease develops because of smoking and alcohol intake.”
2. B)
“Someone in your family must not have been correctly diagnosed with the
disorder.”
3. C)
“Alzheimer disease does not have the same course in every individual.”
4. D)
“There are genetic and environmental factors in the development of Alzheimer
disease.”
Answer: D
Explanation: A) Researchers are not sure why most cases of
Alzheimer disease (AD) arise, although a variety of genetic and environmental
factors appear to be involved. Alzheimer disease is not directly linked to
smoking and alcohol intake. It is inappropriate to assume that other family
members had the disorder but were misdiagnosed. Alzheimer disease has a
predictable course with distinct phases or stages.
1. B)
Researchers are not sure why most cases of Alzheimer disease (AD) arise,
although a variety of genetic and environmental factors appear to be involved.
Alzheimer disease is not directly linked to smoking and alcohol intake. It is
inappropriate to assume that other family members had the disorder but were
misdiagnosed. Alzheimer disease has a predictable course with distinct phases
or stages.
2. C)
Researchers are not sure why most cases of Alzheimer disease (AD) arise,
although a variety of genetic and environmental factors appear to be involved.
Alzheimer disease is not directly linked to smoking and alcohol intake. It is
inappropriate to assume that other family members had the disorder but were
misdiagnosed. Alzheimer disease has a predictable course with distinct phases
or stages.
3. D)
Researchers are not sure why most cases of Alzheimer disease (AD) arise, although
a variety of genetic and environmental factors appear to be involved. Alzheimer
disease is not directly linked to smoking and alcohol intake. It is
inappropriate to assume that other family members had the disorder but were
misdiagnosed. Alzheimer disease has a predictable course with distinct phases
or stages.
Page Ref: 1595
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 1. Describe the pathophysiology,
etiology, clinical manifestations, and direct and indirect causes of Alzheimer
disease.
2) An adult child who has brought the client in to be evaluated
has been told the client has Alzheimer disease. The adult child asks the nurse
if all the children of the client are going to get the disease. What should the
nurse explain as a risk factor for this disease?
Select all that apply.
1. A)
Genetic predisposition
2. B)
Age
3. C)
History of hypertension
4. D)
Race
5. E)
Environmental exposure
Answer: A, B, E
Explanation: A) Growing older is the greatest risk factor
for the development of Alzheimer disease. The combination of genetic
predisposition and environmental factors also affects the risk. Some genetic
mutations on specific chromosomes have been shown to cause Alzheimer disease,
but these genes account for less than 5% of all cases of Alzheimer disease.
There is no indication that race or hypertension plays a role in the
development of Alzheimer disease.
1. B)
Growing older is the greatest risk factor for the development of Alzheimer
disease. The combination of genetic predisposition and environmental factors
also affects the risk. Some genetic mutations on specific chromosomes have been
shown to cause Alzheimer disease, but these genes account for less than 5% of
all cases of Alzheimer disease. There is no indication that race or
hypertension plays a role in the development of Alzheimer disease.
2. C)
Growing older is the greatest risk factor for the development of Alzheimer
disease. The combination of genetic predisposition and environmental factors
also affects the risk. Some genetic mutations on specific chromosomes have been
shown to cause Alzheimer disease, but these genes account for less than 5% of
all cases of Alzheimer disease. There is no indication that race or hypertension
plays a role in the development of Alzheimer disease.
3. D)
Growing older is the greatest risk factor for the development of Alzheimer
disease. The combination of genetic predisposition and environmental factors
also affects the risk. Some genetic mutations on specific chromosomes have been
shown to cause Alzheimer disease, but these genes account for less than 5% of
all cases of Alzheimer disease. There is no indication that race or
hypertension plays a role in the development of Alzheimer disease.
4. E) Growing
older is the greatest risk factor for the development of Alzheimer disease. The
combination of genetic predisposition and environmental factors also affects
the risk. Some genetic mutations on specific chromosomes have been shown to
cause Alzheimer disease, but these genes account for less than 5% of all cases
of Alzheimer disease. There is no indication that race or hypertension plays a
role in the development of Alzheimer disease.
Page Ref: 1595
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 2. Identify risk factors and prevention
methods associated with Alzheimer disease.
3) A client diagnosed with Alzheimer disease has a catastrophic
reaction during an activity involving simultaneous music playing and a craft
project. The client starts shouting, “No! No! No!” and runs from the room. What
should the nurse do?
1. A)
Administer a PRN anti-anxiety medication and restrict the client’s activity
participation.
2. B)
Intervene one-on-one with the client until the client is calm, and then
redirect the client to another activity such as Bingo.
3. C)
Discontinue the activity program because it is upsetting the client.
4. D)
Follow the client, reassure the client one-on-one, and then redirect the client
to a quiet activity.
Answer: D
Explanation: A) Environmental stimuli should be kept at a
minimum for clients with dementia. A quiet environment will prevent sensory
overload. The nurse’s one-on-one intervention with the client will reassure the
client and reduce anxiety. Once the client is less agitated, the client can be
directed to a less stimulating activity.
1. B)
Environmental stimuli should be kept at a minimum for clients with dementia. A
quiet environment will prevent sensory overload. The nurse’s one-on-one
intervention with the client will reassure the client and reduce anxiety. Once
the client is less agitated, the client can be directed to a less stimulating
activity.
2. C)
Environmental stimuli should be kept at a minimum for clients with dementia. A
quiet environment will prevent sensory overload. The nurse’s one-on-one
intervention with the client will reassure the client and reduce anxiety. Once
the client is less agitated, the client can be directed to a less stimulating
activity.
3. D) Environmental
stimuli should be kept at a minimum for clients with dementia. A quiet
environment will prevent sensory overload. The nurse’s one-on-one intervention
with the client will reassure the client and reduce anxiety. Once the client is
less agitated, the client can be directed to a less stimulating activity.
Page Ref: 1601
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Nursing Process: Implementation
Learning Outcome: 3. Illustrate the nursing process in
providing culturally sensitive care across the life span for individuals with
Alzheimer disease.
4) The nurse is planning care for a client with Stage 1
Alzheimer disease. Which one of the following nursing diagnoses would the nurse
base care for this client and family?
1. A)
Impaired Memory and Caregiver Role Strain
2. B)
Hopelessness and Functional Family Processes
3. C)
Knowledge Deficit and Ineffective Coping
4. D)
Pseudohostility and Ineffective Coping
Answer: A
Explanation: A) Appropriate nursing diagnoses may depend
on the stage of Alzheimer disease (AD). Impaired Memory is an appropriate
nursing diagnosis in Stage 1 AD. Caregiver Role Strain is appropriate for any
stage of AD. Functional family processes and ineffective coping are not
diagnoses related to cognitive behavioral assessment. Pseudohostility is not a
nursing diagnosis.
1. B)
Appropriate nursing diagnoses may depend on the stage of Alzheimer disease
(AD). Impaired Memory is an appropriate nursing diagnosis in Stage 1 AD.
Caregiver Role Strain is appropriate for any stage of AD. Functional family
processes and ineffective coping are not diagnoses related to cognitive
behavioral assessment. Pseudohostility is not a nursing diagnosis.
2. C)
Appropriate nursing diagnoses may depend on the stage of Alzheimer disease
(AD). Impaired Memory is an appropriate nursing diagnosis in Stage 1 AD.
Caregiver Role Strain is appropriate for any stage of AD. Functional family
processes and ineffective coping are not diagnoses related to cognitive
behavioral assessment. Pseudohostility is not a nursing diagnosis.
3. D)
Appropriate nursing diagnoses may depend on the stage of Alzheimer disease
(AD). Impaired Memory is an appropriate nursing diagnosis in Stage 1 AD.
Caregiver Role Strain is appropriate for any stage of AD. Functional family processes
and ineffective coping are not diagnoses related to cognitive behavioral
assessment. Pseudohostility is not a nursing diagnosis.
Page Ref: 1600-1601
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Nursing Process: Implementation
Learning Outcome: 4. Formulate priority nursing diagnoses
appropriate for an individual with Alzheimer disease.
5) The nurse is preparing an educational program for the family
of a client with dementia who is ready for discharge. On what should the nurse
focus to reduce the risk for injury?
Select all that apply.
1. A)
Have all objects in the room be the same color.
2. B)
Check shoes for fit and support.
3. C) Be
aware that client in the early stages usually have few problems with unfamiliar
places.
4. D)
Keep all familiar objects in the home.
5. E)
Remove throw rugs and electrical cords.
Answer: B, E
Explanation: A) Clients with chronic confusion, as often
seen with dementia, are at increased risk for falls. Shoes should fit and be
supportive. Simplifying the home environment while keeping familiar furniture
in the same space will assist the client to cope better safely. Clutter should
be removed to reduce anxiety and suspicions, and to promote safety. The concept
of “pop up”–using a contrast in colors to assist the client in finding an
object in a room–should be explained to caregivers. For example, a white toilet
in a blue room is easier to distinguish than a white toilet in a white room.
Even in early stages of dementia, clients have difficulty dealing with
unfamiliar places.
1. B)
Clients with chronic confusion, as often seen with dementia, are at increased
risk for falls. Shoes should fit and be supportive. Simplifying the home
environment while keeping familiar furniture in the same space will assist the
client to cope better safely. Clutter should be removed to reduce anxiety and
suspicions, and to promote safety. The concept of “pop up”–using a contrast in
colors to assist the client in finding an object in a room–should be explained
to caregivers. For example, a white toilet in a blue room is easier to
distinguish than a white toilet in a white room. Even in early stages of
dementia, clients have difficulty dealing with unfamiliar places.
2. C)
Clients with chronic confusion, as often seen with dementia, are at increased
risk for falls. Shoes should fit and be supportive. Simplifying the home
environment while keeping familiar furniture in the same space will assist the
client to cope better safely. Clutter should be removed to reduce anxiety and
suspicions, and to promote safety. The concept of “pop up”–using a contrast in
colors to assist the client in finding an object in a room–should be explained
to caregivers. For example, a white toilet in a blue room is easier to
distinguish than a white toilet in a white room. Even in early stages of
dementia, clients have difficulty dealing with unfamiliar places.
3. D)
Clients with chronic confusion, as often seen with dementia, are at increased
risk for falls. Shoes should fit and be supportive. Simplifying the home
environment while keeping familiar furniture in the same space will assist the
client to cope better safely. Clutter should be removed to reduce anxiety and
suspicions, and to promote safety. The concept of “pop up”–using a contrast in
colors to assist the client in finding an object in a room–should be explained
to caregivers. For example, a white toilet in a blue room is easier to
distinguish than a white toilet in a white room. Even in early stages of
dementia, clients have difficulty dealing with unfamiliar places.
1. E)
Clients with chronic confusion, as often seen with dementia, are at increased
risk for falls. Shoes should fit and be supportive. Simplifying the home
environment while keeping familiar furniture in the same space will assist the client
to cope better safely. Clutter should be removed to reduce anxiety and
suspicions, and to promote safety. The concept of “pop up”–using a contrast in
colors to assist the client in finding an object in a room–should be explained
to caregivers. For example, a white toilet in a blue room is easier to
distinguish than a white toilet in a white room. Even in early stages of
dementia, clients have difficulty dealing with unfamiliar places.
Page Ref: 1601
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an
individual with Alzheimer disease and his or her family in collaboration with
other members of the healthcare team.
6) The nurse is planning care for a client who is experiencing
Stage 1 Alzheimer disease. What will promote a therapeutic environment for a
client with acute confusion?
1. A)
Background noise like music will keep this client calm.
2. B)
Dim the lights during waking hours.
3. C)
Schedule meals at the same time each day.
4. D)
Pain medications will enhance the therapeutic environment.
Answer: C
Explanation: A) The client with dementia benefits from a
routine schedule of activities, including meal times. The client typically is
better oriented when it is quiet. Pain medications should be administered if
pain is present, but these medications will not enhance the therapeutic
environment. It is important keep the room lit during waking hours; the lights
should not be dimmed during this time.
1. B) The
client with dementia benefits from a routine schedule of activities, including
meal times. The client typically is better oriented when it is quiet. Pain
medications should be administered if pain is present, but these medications
will not enhance the therapeutic environment. It is important keep the room lit
during waking hours; the lights should not be dimmed during this time.
2. C)
The client with dementia benefits from a routine schedule of activities,
including meal times. The client typically is better oriented when it is quiet.
Pain medications should be administered if pain is present, but these
medications will not enhance the therapeutic environment. It is important keep
the room lit during waking hours; the lights should not be dimmed during this
time.
3. D)
The client with dementia benefits from a routine schedule of activities,
including meal times. The client typically is better oriented when it is quiet.
Pain medications should be administered if pain is present, but these
medications will not enhance the therapeutic environment. It is important keep
the room lit during waking hours; the lights should not be dimmed during this
time.
Page Ref: 1601
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an
individual with Alzheimer disease and his or her family in collaboration with
other members of the healthcare team.
7) The nurse includes information regarding long-term care
placement in the discharge materials for the family of a client newly diagnosed
with Alzheimer disease. Why is this information important to provide to the
family at this time?
1. A) It
often takes 6 to12 months for an individual with Alzheimer disease to establish
a successful transfer to a facility, and this will allow adequate time.
2. B)
It’s better to address the issue of placement now instead of later.
3. C)
Early introduction to long-term options will allow the client and family time
to make a more informed decision.
4. D)
Long-term care placement is inevitable with this diagnosis.
Answer: C
Explanation: A) Although placement in a long-term care
facility is not going to be the fate of all individuals with Alzheimer disease,
it is a common one. Providing the information early in the disease process
allows the family to make an informed choice. Nurses will need to provide
reinforced education and referrals throughout the disease process, not just
during the initial hospitalization. There is no plan to transfer the client at
this time; adjustment would occur after the transfer.
1. B)
Although placement in a long-term care facility is not going to be the fate of
all individuals with Alzheimer disease, it is a common one. Providing the
information early in the disease process allows the family to make an informed
choice. Nurses will need to provide reinforced education and referrals
throughout the disease process, not just during the initial hospitalization.
There is no plan to transfer the client at this time; adjustment would occur
after the transfer.
2. C)
Although placement in a long-term care facility is not going to be the fate of
all individuals with Alzheimer disease, it is a common one. Providing the
information early in the disease process allows the family to make an informed
choice. Nurses will need to provide reinforced education and referrals
throughout the disease process, not just during the initial hospitalization.
There is no plan to transfer the client at this time; adjustment would occur
after the transfer.
3. D)
Although placement in a long-term care facility is not going to be the fate of
all individuals with Alzheimer disease, it is a common one. Providing the
information early in the disease process allows the family to make an informed
choice. Nurses will need to provide reinforced education and referrals
throughout the disease process, not just during the initial hospitalization.
There is no plan to transfer the client at this time; adjustment would occur
after the transfer.
Page Ref: 1598
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an
individual with Alzheimer disease and his or her family in collaboration with
other members of the healthcare team.
8) A client has been diagnosed as having Stage 1 Alzheimer
disease. What would be the goal for the client and the family at this time?
Select all that apply.
1. A)
Resolving grief over the diagnosis
2. B)
Deciding on the desired treatment and selecting a healthcare proxy; sharing the
treatment decision with the healthcare proxy
3. C)
Beginning cognitive-enhancing medication, such as Aricept
4. D)
Setting up a protective physical environment–such as removing throw rugs
Answer: A, B, C, D
Explanation: A) Grieving over the diagnosis and loss of
functioning and mental abilities will be an ongoing process for the client and
the family members and is therefore a goal. While the client is still
cognizant, it is important that the client and family discuss the desired
treatment and designate a healthcare proxy to carry out the client’s wishes
regarding the treatment. Clients with early Alzheimer disease should start the
cholinesterase inhibitor medication as soon as possible to extend the early
stage of the disease. During this time period, the home environment should be
modified to balance safety with client autonomy.
1. B)
Grieving over the diagnosis and loss of functioning and mental abilities will
be an ongoing process for the client and the family members and is therefore a
goal. While the client is still cognizant, it is important that the client and
family discuss the desired treatment and designate a healthcare proxy to carry
out the client’s wishes regarding the treatment. Clients with early Alzheimer
disease should start the cholinesterase inhibitor medication as soon as
possible to extend the early stage of the disease. During this time period, the
home environment should be modified to balance safety with client autonomy.
2. C)
Grieving over the diagnosis and loss of functioning and mental abilities will
be an ongoing process for the client and the family members and is therefore a
goal. While the client is still cognizant, it is important that the client and
family discuss the desired treatment and designate a healthcare proxy to carry
out the client’s wishes regarding the treatment. Clients with early Alzheimer
disease should start the cholinesterase inhibitor medication as soon as
possible to extend the early stage of the disease. During this time period, the
home environment should be modified to balance safety with client autonomy.
3. D)
Grieving over the diagnosis and loss of functioning and mental abilities will
be an ongoing process for the client and the family members and is therefore a
goal. While the client is still cognizant, it is important that the client and
family discuss the desired treatment and designate a healthcare proxy to carry
out the client’s wishes regarding the treatment. Clients with early Alzheimer
disease should start the cholinesterase inhibitor medication as soon as
possible to extend the early stage of the disease. During this time period, the
home environment should be modified to balance safety with client autonomy.
Page Ref: 1599
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Nursing Process: Planning
Learning Outcome: 7. Evaluate expected outcomes for an
individual with Alzheimer disease.
9) A client with Alzheimer disease is scheduled to attend
occupational therapy three times a week. What is the purpose of the client
attending this type of therapy?
1. A)
Improve language deficits
2. B)
Improve muscle tone
3. C)
Perform activities of daily living
4. D)
Improve access to community organizations
Answer: C
Explanation: A) Individuals who are starting to experience
language deficits may be able to slow this decline by working with a speech
therapist. Physical therapy can help individuals improve their muscle tone,
maintain coordination, and maintain their range of motion. Occupational therapy
helps the client maintain the ability to perform many activities of daily
living. Access to community organizations is facilitated through the use of
social workers.
1. B)
Individuals who are starting to experience language deficits may be able to
slow this decline by working with a speech therapist. Physical therapy can help
individuals improve their muscle tone, maintain coordination, and maintain
their range of motion. Occupational therapy helps the client maintain the
ability to perform many activities of daily living. Access to community
organizations is facilitated through the use of social workers.
2. C)
Individuals who are starting to experience language deficits may be able to
slow this decline by working with a speech therapist. Physical therapy can help
individuals improve their muscle tone, maintain coordination, and maintain
their range of motion. Occupational therapy helps the client maintain the
ability to perform many activities of daily living. Access to community
organizations is facilitated through the use of social workers.
3. D)
Individuals who are starting to experience language deficits may be able to
slow this decline by working with a speech therapist. Physical therapy can help
individuals improve their muscle tone, maintain coordination, and maintain
their range of motion. Occupational therapy helps the client maintain the
ability to perform many activities of daily living. Access to community
organizations is facilitated through the use of social workers.
Page Ref: 1598
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 5. Summarize therapies used by
interdisciplinary teams in the collaborative care of an individual with
Alzheimer disease.
10) The nurse plans a class about Alzheimer disease for a
caregiver support group. What should the nurse include when teaching this class
of caregivers?
Select all that apply.
1. A)
Glutamatergic inhibitors are the most common class of drugs for treating
Alzheimer disease.
2. B)
Alzheimer disease accounts for about 70% of all dementias.
3. C)
Chronic inflammation of the brain may be a cause of the disease.
4. D)
Depression and aggressive behavior are common with the disease.
5. E)
Memory difficulties are an early symptom of the disease.
Answer: B, C, D, E
Explanation: A) Memory difficulties are an early symptom
of Alzheimer disease. It is suspected that chronic inflammation and excess free
radicals may cause neuron damage, which contributes to the disease. Depression
and aggressive behavior are common symptoms of the disease. Alzheimer disease
accounts for about 70% of all dementias. The acetylcholinesterase inhibitors,
not the glutamatergic inhibitors, are the most widely used class of drugs for
treating the disease.
1. B)
Memory difficulties are an early symptom of Alzheimer disease. It is suspected
that chronic inflammation and excess free radicals may cause neuron damage,
which contributes to the disease. Depression and aggressive behavior are common
symptoms of the disease. Alzheimer disease accounts for about 70% of all
dementias. The acetylcholinesterase inhibitors, not the glutamatergic
inhibitors, are the most widely used class of drugs for treating the disease.
2. C)
Memory difficulties are an early symptom of Alzheimer disease. It is suspected
that chronic inflammation and excess free radicals may cause neuron damage,
which contributes to the disease. Depression and aggressive behavior are common
symptoms of the disease. Alzheimer disease accounts for about 70% of all
dementias. The acetylcholinesterase inhibitors, not the glutamatergic
inhibitors, are the most widely used class of drugs for treating the disease.
3. D)
Memory difficulties are an early symptom of Alzheimer disease. It is suspected
that chronic inflammation and excess free radicals may cause neuron damage,
which contributes to the disease. Depression and aggressive behavior are common
symptoms of the disease. Alzheimer disease accounts for about 70% of all
dementias. The acetylcholinesterase inhibitors, not the glutamatergic
inhibitors, are the most widely used class of drugs for treating the disease.
4. E)
Memory difficulties are an early symptom of Alzheimer disease. It is suspected
that chronic inflammation and excess free radicals may cause neuron damage,
which contributes to the disease. Depression and aggressive behavior are common
symptoms of the disease. Alzheimer disease accounts for about 70% of all
dementias. The acetylcholinesterase inhibitors, not the glutamatergic
inhibitors, are the most widely used class of drugs for treating the disease.
Page Ref: 1601
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 1. Describe the pathophysiology,
etiology, clinical manifestations, and direct and indirect causes of Alzheimer
disease.
11) The nurse is reviewing content provided to a caregiver of an
individual with Alzheimer disease. Which statement indicates that teaching has
been effective?
1. A)
“There are effective drugs, but they cannot be used over a long period.”
2. B)
“There aren’t any drugs that are effective in treating this disease.”
3. C)
“The earlier the drugs are started, the greater the effect they will have on
the disease.”
4. D)
“There are drugs that can control symptoms for many years.”
Answer: C
Explanation: A) The earlier the medications are started,
the greater the effect they will have on the symptoms of Alzheimer disease.
Current medications will only decrease symptoms for a short period of time.
Drugs will not control symptoms for many years. The drugs for treatment of
Alzheimer disease are no more dangerous than other drugs used for a long period
of time.
1. B)
The earlier the medications are started, the greater the effect they will have
on the symptoms of Alzheimer disease. Current medications will only decrease
symptoms for a short period of time. Drugs will not control symptoms for many
years. The drugs for treatment of Alzheimer disease are no more dangerous than
other drugs used for a long period of time.
2. C)
The earlier the medications are started, the greater the effect they will have
on the symptoms of Alzheimer disease. Current medications will only decrease
symptoms for a short period of time. Drugs will not control symptoms for many
years. The drugs for treatment of Alzheimer disease are no more dangerous than
other drugs used for a long period of time.
3. D)
The earlier the medications are started, the greater the effect they will have
on the symptoms of Alzheimer disease. Current medications will only decrease
symptoms for a short period of time. Drugs will not control symptoms for many years.
The drugs for treatment of Alzheimer disease are no more dangerous than other
drugs used for a long period of time.
Page Ref: 1597
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for an
individual with Alzheimer disease.
12) A home health nurse visits a client with Stage 2 Alzheimer
disease who lives at home with a spouse. What should the nurse suggest to meet
the needs of the client’s spouse?
1. A)
Encouraging the caregiver to take rest periods and avoid fatigue
2. B)
Providing the client a list of daily activities to complete
3. C)
Making arrangements for the client to visit the local senior citizen center in
the afternoon
4. D)
Finding placement in a long-term care facility
Answer: A
Explanation: A) Stage 2 clients are generally more
confused, can demonstrate repetitive behavior, are less able to make simple
decisions and to adapt to environmental changes, and are often unable to carry
out activities of daily living. The spouse needs opportunities to have breaks
from the demands of the client’s care and should be encouraged to take rest
periods and avoid fatigue. Because the Stage 2 client does not adapt well to
changes in the environment, it would be best to have someone come into the
home, rather than to have the client go out. An outing or a list of activities
would be better suited for the client in Stage 1. Recommending placement in
long-term care might be premature, and is not up to the nurse.
1. B)
Stage 2 clients are generally more confused, can demonstrate repetitive
behavior, are less able to make simple decisions and to adapt to environmental
changes, and are often unable to carry out activities of daily living. The
spouse needs opportunities to have breaks from the demands of the client’s care
and should be encouraged to take rest periods and avoid fatigue. Because the
Stage 2 client does not adapt well to changes in the environment, it would be
best to have someone come into the home, rather than to have the client go out.
An outing or a list of activities would be better suited for the client in
Stage 1. Recommending placement in long-term care might be premature, and is
not up to the nurse.
2. C)
Stage 2 clients are generally more confused, can demonstrate repetitive
behavior, are less able to make simple decisions and to adapt to environmental
changes, and are often unable to carry out activities of daily living. The
spouse needs opportunities to have breaks from the demands of the client’s care
and should be encouraged to take rest periods and avoid fatigue. Because the
Stage 2 client does not adapt well to changes in the environment, it would be
best to have someone come into the home, rather than to have the client go out.
An outing or a list of activities would be better suited for the client in
Stage 1. Recommending placement in long-term care might be premature, and is
not up to the nurse.
3. D)
Stage 2 clients are generally more confused, can demonstrate repetitive
behavior, are less able to make simple decisions and to adapt to environmental
changes, and are often unable to carry out activities of daily living. The
spouse needs opportunities to have breaks from the demands of the client’s care
and should be encouraged to take rest periods and avoid fatigue. Because the
Stage 2 client does not adapt well to changes in the environment, it would be
best to have someone come into the home, rather than to have the client go out.
An outing or a list of activities would be better suited for the client in
Stage 1. Recommending placement in long-term care might be premature, and is
not up to the nurse.
Page Ref: 1602-1603
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an
individual with Alzheimer disease and his or her family in collaboration with
other members of the healthcare team.
13) A nurse is caring for a client with Alzheimer disease (AD)
who has receptive aphasia. Which area of the brain is likely damaged from AD?
1. A)
Temporal lobe
2. B)
Limbic system
3. C)
Frontal lobe
4. D)
Occipital lobe
Answer: A
Explanation: A) Damage to the client’s temporal lobe
causes receptive aphasia. Damage to the limbic system manifests as loss of
memory, fluctuating emotions, depression, and difficulty learning new things.
Damage to the frontal lobe manifests as problems with intentional movement,
fluctuating emotions, and loss of the ability to walk. Frontal lobe damage
causes loss of the ability to talk and the ability to swallow. Damage to the
occipital lobe results in loss of reading comprehension and hallucinations.
1. B)
Damage to the client’s temporal lobe causes receptive aphasia. Damage to the
limbic system manifests as loss of memory, fluctuating emotions, depression,
and difficulty learning new things. Damage to the frontal lobe manifests as
problems with intentional movement, fluctuating emotions, and loss of the
ability to walk. Frontal lobe damage causes loss of the ability to talk and the
ability to swallow. Damage to the occipital lobe results in loss of reading
comprehension and hallucinations.
2. C)
Damage to the client’s temporal lobe causes receptive aphasia. Damage to the
limbic system manifests as loss of memory, fluctuating emotions, depression,
and difficulty learning new things. Damage to the frontal lobe manifests as
problems with intentional movement, fluctuating emotions, and loss of the
ability to walk. Frontal lobe damage causes loss of the ability to talk and the
ability to swallow. Damage to the occipital lobe results in loss of reading
comprehension and hallucinations.
3. D)
Damage to the client’s temporal lobe causes receptive aphasia. Damage to the
limbic system manifests as loss of memory, fluctuating emotions, depression,
and difficulty learning new things. Damage to the frontal lobe manifests as
problems with intentional movement, fluctuating emotions, and loss of the
ability to walk. Frontal lobe damage causes loss of the ability to talk and the
ability to swallow. Damage to the occipital lobe results in loss of reading
comprehension and hallucinations.
Page Ref: 1595
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology,
etiology, clinical manifestations, and direct and indirect causes of Alzheimer
disease.
14) A student nurse is reviewing the pathophysiology and
etiology of Alzheimer disease (AD). What is true regarding the pathophysiology
and etiology of this disease?
Select all that apply.
1. A)
Damage to the limbic system results in speech decline and slowed movements.
2. B)
Familial Alzheimer disease (FAD) is also called delayed-onset Alzheimer
disease.
3. C)
Sporadic Alzheimer disease usually manifests before age 65.
4. D)
Sporadic Alzheimer disease is more common than familial Alzheimer disease.
5. E) In
Alzheimer disease, neuronal cells die in a characteristic order.
Answer: D, E
Explanation: A) In Alzheimer disease, the neuronal cells
die in a characteristic order, beginning with neurons in the limbic system,
including the hippocampus. There are two basic types of AD: familial and
sporadic. Familial AD (FAD) has a strong inherited component and is also called
early-onset AD because it usually manifests before age 65. Sporadic AD shows no
clear pattern of inheritance, although genetic factors may be involved. Because
it typically develops after age 65, sporadic AD is sometimes referred to as
late-onset AD. Damage to the limbic system from AD results in memory loss and
emotional problems.
65. B) In
Alzheimer disease, the neuronal cells die in a characteristic order, beginning
with neurons in the limbic system, including the hippocampus. There are two
basic types of AD: familial and sporadic. Familial AD (FAD) has a strong
inherited component and is also called early-onset AD because it usually
manifests before age 65. Sporadic AD shows no clear pattern of inheritance,
although genetic factors may be involved. Because it typically develops after
age 65, sporadic AD is sometimes referred to as late-onset AD. Damage to the
limbic system from AD results in memory loss and emotional problems.
66. C) In
Alzheimer disease, the neuronal cells die in a characteristic order, beginning
with neurons in the limbic system, including the hippocampus. There are two basic
types of AD: familial and sporadic. Familial AD (FAD) has a strong inherited
component and is also called early-onset AD because it usually manifests before
age 65. Sporadic AD shows no clear pattern of inheritance, although genetic
factors may be involved. Because it typically develops after age 65, sporadic
AD is sometimes referred to as late-onset AD. Damage to the limbic system from
AD results in memory loss and emotional problems.
67. D) In
Alzheimer disease, the neuronal cells die in a characteristic order, beginning
with neurons in the limbic system, including the hippocampus. There are two
basic types of AD: familial and sporadic. Familial AD (FAD) has a strong
inherited component and is also called early-onset AD because it usually
manifests before age 65. Sporadic AD shows no clear pattern of inheritance,
although genetic factors may be involved. Because it typically develops after
age 65, sporadic AD is sometimes referred to as late-onset AD. Damage to the
limbic system from AD results in memory loss and emotional problems.
65. E) In
Alzheimer disease, the neuronal cells die in a characteristic order, beginning
with neurons in the limbic system, including the hippocampus. There are two
basic types of AD: familial and sporadic. Familial AD (FAD) has a strong
inherited component and is also called early-onset AD because it usually
manifests before age 65. Sporadic AD shows no clear pattern of inheritance,
although genetic factors may be involved. Because it typically develops after
age 65, sporadic AD is sometimes referred to as late-onset AD. Damage to the
limbic system from AD results in memory loss and emotional problems.
Page Ref: 1596
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology,
etiology, clinical manifestations, and direct and indirect causes of Alzheimer
disease.
15) A nurse is caring for a client with Alzheimer disease (AD)
who just recently lost the ability to live independently but can still perform
activities of daily living (ADLs). Which stage of the disease is this client
in?
1. A)
Stage 3
2. B)
Stage 4
3. C)
Stage 5
4. D)
Stage 6
Answer: C
Explanation: A) This client is in Stage 5 (moderate AD)
because the client has lost the ability to live independently. In this stage,
the client may be unable to choose appropriate clothing or prepare food and is
at increased risk of someone taking advantage of him or her because of loss of
cognition and lack of safety awareness. A client in Stage 3 (mild cognitive
impairment) is able to maintain living independently, but the client’s memory
lapses are apparent to others. In Stage 6 (moderately severe AD), individuals
become unable to perform even basic activities of daily living (ADLs).
1. B)
This client is in Stage 5 (moderate AD) because the client has lost the ability
to live independently. In this stage, the client may be unable to choose
appropriate clothing or prepare food and is at increased risk of someone taking
advantage of him or her because of loss of cognition and lack of safety
awareness. A client in Stage 3 (mild cognitive impairment) is able to maintain
living independently, but the client’s memory lapses are apparent to others. In
Stage 6 (moderately severe AD), individuals become unable to perform even basic
activities of daily living (ADLs).
2. C)
This client is in Stage 5 (moderate AD) because the client has lost the ability
to live independently. In this stage, the client may be unable to choose
appropriate clothing or prepare food and is at increased risk of someone taking
advantage of him or her because of loss of cognition and lack of safety
awareness. A client in Stage 3 (mild cognitive impairment) is able to maintain
living independently, but the client’s memory lapses are apparent to others. In
Stage 6 (moderately severe AD), individuals become unable to perform even basic
activities of daily living (ADLs).
3. D)
This client is in Stage 5 (moderate AD) because the client has lost the ability
to live independently. In this stage, the client may be unable to choose
appropriate clothing or prepare food and is at increased risk of someone taking
advantage of him or her because of loss of cognition and lack of safety
awareness. A client in Stage 3 (mild cognitive impairment) is able to maintain
living independently, but the client’s memory lapses are apparent to others. In
Stage 6 (moderately severe AD), individuals become unable to perform even basic
activities of daily living (ADLs).
Page Ref: 1597
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology,
etiology, clinical manifestations, and direct and indirect causes of Alzheimer
disease.
Exemplar 23.2 Confusion
1) The client’s family says, “We don’t understand what is
happening to Dad. He becomes very agitated in the evenings, cussing like a
sailor.” What should the nurse explain is occurring with the client?
1. A)
Delirium
2. B)
Sundown syndrome
3. C)
Anxiety
4. D)
Psychosis
Answer: B
Explanation: A) Sundown syndrome, or sundowning, is
understood as confused behavior when the environmental stimulation is low. It
is seen in clients with delirium and dementia who are institutionalized. The
client can become increasingly agitated, disoriented, or even aggressive/paranoid
or impulsive and emotional later in the day and at night. Delirium is a
rapid-onset type of confusion. Anxiety does not come and go; it is a state of
mind. Psychosis is a mental disorder, and this client is not exhibiting signs
of psychosis.
1. B) Sundown
syndrome, or sundowning, is understood as confused behavior when the
environmental stimulation is low. It is seen in clients with delirium and
dementia who are institutionalized. The client can become increasingly
agitated, disoriented, or even aggressive/paranoid or impulsive and emotional
later in the day and at night. Delirium is a rapid-onset type of confusion.
Anxiety does not come and go; it is a state of mind. Psychosis is a mental
disorder, and this client is not exhibiting signs of psychosis.
2. C)
Sundown syndrome, or sundowning, is understood as confused behavior when the
environmental stimulation is low. It is seen in clients with delirium and
dementia who are institutionalized. The client can become increasingly
agitated, disoriented, or even aggressive/paranoid or impulsive and emotional
later in the day and at night. Delirium is a rapid-onset type of confusion.
Anxiety does not come and go; it is a state of mind. Psychosis is a mental
disorder, and this client is not exhibiting signs of psychosis.
3. D)
Sundown syndrome, or sundowning, is understood as confused behavior when the
environmental stimulation is low. It is seen in clients with delirium and
dementia who are institutionalized. The client can become increasingly
agitated, disoriented, or even aggressive/paranoid or impulsive and emotional
later in the day and at night. Delirium is a rapid-onset type of confusion.
Anxiety does not come and go; it is a state of mind. Psychosis is a mental
disorder, and this client is not exhibiting signs of psychosis.
Page Ref: 1597
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Nursing Process: Implementation
Learning Outcome: 1. Describe the pathophysiology,
etiology, clinical manifestations, and direct and indirect causes of confusion.
2) The family of an older client is informed that the client has
delirium. Which statement indicates that the family understands the diagnosis?
1. A)
“Dad has always been so independent. He’s lived alone for years since my mom
died.”
2. B)
“The changes in his behavior came on so quickly. He was fine when he woke up
but didn’t know the year or where he was by lunch time.”
3. C)
“Dad has been becoming increasingly forgetful over the last several months.”
4. D)
“Maybe it’s just caused by aging. This usually happens when people get older.”
Answer: B
Explanation: A) Delirium is characterized by a rapid and
abrupt onset of symptoms. Although delirium is more common in older
individuals, aging is not a cause of delirium. Impairments in short-term memory
are more indicative of dementia. The fact that he had been independent has no
bearing on his current symptoms.
1. B)
Delirium is characterized by a rapid and abrupt onset of symptoms. Although
delirium is more common in older individuals, aging is not a cause of delirium.
Impairments in short-term memory are more indicative of dementia. The fact that
he had been independent has no bearing on his current symptoms.
2. C)
Delirium is characterized by a rapid and abrupt onset of symptoms. Although
delirium is more common in older individuals, aging is not a cause of delirium.
Impairments in short-term memory are more indicative of dementia. The fact that
he had been independent has no bearing on his current symptoms.
3. D)
Delirium is characterized by a rapid and abrupt onset of symptoms. Although
delirium is more common in older individuals, aging is not a cause of delirium.
Impairments in short-term memory are more indicative of dementia. The fact that
he had been independent has no bearing on his current symptoms.
Page Ref: 1606
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Nursing Process: Evaluation
Learning Outcome: 1. Describe the pathophysiology,
etiology, clinical manifestations, and direct and indirect causes of confusion.
3) An older hospitalized client wakes up in the middle of the
night very confused. The nurse reorients the client to the surroundings and
gets the client to return to sleep. What should the nurse consider as a source
for the client’s confusion?
1. A)
Ambien 10 mg as needed at bedtime for sleep
2. B)
The client’s age
3. C)
The death of the client’s husband last month
4. D)
History of cardiac disease
Answer: A
Explanation: A) Certain medications, such as sleeping
pills, tranquilizers, and pain medications, can cause symptoms similar to
dementia. Therefore, the client’s medication must be reviewed to determine the
effects of drugs and cognitive changes. Although loss of a loved one may result
in depression, it is unlikely to be the source of confusion. Age alone does not
cause confusion, and cardiac disease alone would not cause confusion.
1. B)
Certain medications, such as sleeping pills, tranquilizers, and pain
medications, can cause symptoms similar to dementia. Therefore, the client’s
medication must be reviewed to determine the effects of drugs and cognitive
changes. Although loss of a loved one may result in depression, it is unlikely
to be the source of confusion. Age alone does not cause confusion, and cardiac
disease alone would not cause confusion.
2. C)
Certain medications, such as sleeping pills, tranquilizers, and pain
medications, can cause symptoms similar to dementia. Therefore, the client’s
medication must be reviewed to determine the effects of drugs and cognitive
changes. Although loss of a loved one may result in depression, it is unlikely
to be the source of confusion. Age alone does not cause confusion, and cardiac
disease alone would not cause confusion.
3. D)
Certain medications, such as sleeping pills, tranquilizers, and pain
medications, can cause symptoms similar to dementia. Therefore, the client’s
medication must be reviewed to determine the effects of drugs and cognitive
changes. Although loss of a loved one may result in depression, it is unlikely
to be the source of confusion. Age alone does not cause confusion, and cardiac
disease alone would not cause confusion.
Page Ref: 1606
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Nursing Process: Assessment
Learning Outcome: 2. Identify risk factors and prevention
methods associated with confusion.
4) A non-English-speaking child is hospitalized with
encephalitis and is experiencing delirium. Which intervention promotes a
therapeutic environment for this child and family?
1. A)
Making sure the parents can set up the treatments for their child
2. B)
Encouraging the family to remain at the bedside with the client
3. C)
Making sure the child comes back for the follow-up appointment
4. D)
Providing written instructions before discharge
Answer: B
Explanation: A) Encouraging the family to remain at the
bedside with the client will promote a therapeutic environment for a client
experiencing delirium caused by encephalitis. All of the other interventions
are important for the discharge planning of this client.
1. B)
Encouraging the family to remain at the bedside with the client will promote a
therapeutic environment for a client experiencing delirium caused by
encephalitis. All of the other interventions are important for the discharge
planning of this client.
2. C)
Encouraging the family to remain at the bedside with the client will promote a
therapeutic environment for a client experiencing delirium caused by
encephalitis. All of the other interventions are important for the discharge
planning of this client.
3. D)
Encouraging the family to remain at the bedside with the client will promote a
therapeutic environment for a client experiencing delirium caused by
encephalitis. All of the other interventions are important for the discharge
planning of this client.
Page Ref: 1609
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Nursing Process: Implementation
Learning Outcome: 3. Illustrate the nursing process in
providing culturally sensitive care across the life span for individuals with
confusion.
5) A hospitalized elderly client suddenly does not recognize his
daughter and complains that his wife has not visited him, even though she has
been dead for 5 years. The client was clear of mind and thought prior to
hospitalization. Which nursing diagnosis or diagnoses would be appropriate for
this client?
Select all that apply.
1. A)
Risk for Autonomic Dysreflexia
2. B)
Anxiety
3. C)
Acute Confusion
4. D)
Impaired Memory
5. E)
Ineffective Coping
Answer: C, D
Explanation: A) The client is experiencing acute confusion
and impaired memory according to the scenario presented. The scenario does not
indicate the client is experiencing anxiety or ineffective coping. Autonomic
dysreflexia is a syndrome of clients with spinal cord damage, which is not
indicated for this client.
1. B)
The client is experiencing acute confusion and impaired memory according to the
scenario presented. The scenario does not indicate the client is experiencing
anxiety or ineffective coping. Autonomic dysreflexia is a syndrome of clients
with spinal cord damage, which is not indicated for this client.
2. C)
The client is experiencing acute confusion and impaired memory according to the
scenario presented. The scenario does not indicate the client is experiencing
anxiety or ineffective coping. Autonomic dysreflexia is a syndrome of clients
with spinal cord damage, which is not indicated for this client.
3. D)
The client is experiencing acute confusion and impaired memory according to the
scenario presented. The scenario does not indicate the client is experiencing
anxiety or ineffective coping. Autonomic dysreflexia is a syndrome of clients
with spinal cord damage, which is not indicated for this client.
4. E)
The client is experiencing acute confusion and impaired memory according to the
scenario presented. The scenario does not indicate the client is experiencing
anxiety or ineffective coping. Autonomic dysreflexia is a syndrome of clients
with spinal cord damage, which is not indicated for this client.
Page Ref: 1608
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Nursing Process: Planning
Learning Outcome: 4. Formulate priority nursing diagnoses
appropriate for an individual with confusion.
6) The staff on a care area that has a high percentage of
clients with confusion attends an educational program on delirium management.
Which staff nurse statement indicates that teaching has been effective?
1. A)
“It is important to provide education for family members as needed.”
2. B)
“Sensory deprivation and overstimulation can worsen the symptoms the client
exhibits.”
3. C)
“Decreasing all stimulation in the client’s room is essential.”
4. D)
“The family should involve the client in all conversations and interactions
involving care.”
Answer: B
Explanation: A) The structure of the client’s environment
should support cognitive functions. Aids for hearing or vision are necessary to
prevent sensory loss or distortion. Familiar objects from home, such as
slippers, robe, and photographs, may help with orientation. Easily read clocks,
orientation boards, and a structured routine that includes physical activity
and socialization without sensory overload will also help with orientation.
Clients with delirium can exhibit hyperactivity when overstimulated.
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