Not dementia, not depression
Which finding BEST helps the nurse distinguish delirium from dementia?
A. The client has trouble remembering recent events.
B. The client’s confusion began over hours to days and changes throughout the day.
C. The client has difficulty finding the right words.
D. The client needs help with dressing and bathing.
B. The client’s confusion began over hours to days and changes throughout the day.
A client with Alzheimer's disease started donepezil 2 weeks ago. Which finding should the nurse report to the provider IMMEDIATELY?
a. Increased vivid dreams during the night
b. Nausea that resolves within an hour of the morning dose
c. Pulse of 46 beats/min with a near syncopal episode when standing
d. A 1 lb weight loss since the start of therapy
c. Pulse of 46 beats/min with a near syncopal episode when standing
A 24-year-old woman is admitted after superficial cuts to her forearm. She says she has "always felt empty." Over the last week she has gone from euphoric to hopeless to enraged within a single day, usually after her boyfriend didn't text back. She has been irritable, with variable sleep. She denies a time when she needed little sleep, had racing thoughts, or had markedly increased energy for days. Which finding BEST suggests borderline personality disorder rather than bipolar disorder?
a. Self-harm episodes during low moods
b. Duration of mood shifts triggered by perceived interpersonal rejection
c. Reckless spending during the euphoric periods
d. Irritability and variable sleep
b. Duration of mood shifts triggered by perceived interpersonal rejection
Which of the following manifestations indicate ADHD rather than Autism Spectrum Disorder?
a. Intellectual difficulties
b. Social difficulties that stem from interrupting others and inattention
c. Social difficulties that stem from a lack of understanding social cues
d. Need for routine and sameness
b. Social difficulties that stem from interrupting others and inattention
A 5-year-old with autism spectrum disorder who uses limited speech is hospitalized and needs a venipuncture. He is rocking and covering his ears. Which nursing approach is BEST?
a. Tell him, "This will just be a quick pinch, like a bug bite," to keep it simple
b. Ask him to look at you while you explain, so you know he understands
c. Explain the procedure using a picture sequence, use short concrete words, dim lights, and reduce noise first
d. Have several staff members assist to complete the procedure quickly
c. Explain the procedure using a picture sequence, use short concrete words, dim lights, and reduce noise first
Which client is at HIGHEST risk for developing delirium?
A. A 30-year-old recovering from an appendectomy
B. A 78-year-old with mild dementia in the ICU who has a urinary catheter
C. A 55-year-old at a clinic visit for hypertension
D. A 45-year-old with a sprained ankle
B. A 78-year-old with mild dementia in the ICU who has a urinary catheter
A client with moderate Alzheimer's disease becomes agitated each evening, pacing and saying, "I need to go home. My mother is waiting for me." Her mother died decades ago. Which response by the nurse is MOST therapeutic?
a. “Your mother passed away years ago. You are in the hospital now.”
b. “Your mother will come later. Please wait in your room until then.”
c. “Your mother isn’t coming. Let’s sit down and watch television.”
d. “You’re worried about your mother. Tell me about her while we take a walk.”
d. “You’re worried about your mother. Tell me about her while we take a walk.”
After a visit from a family member, a client with borderline personality disorder is found in the bathroom with several shallow lacerations on the forearm. The client says, “I just needed to feel something.” Which action should the nurse take FIRST?
a. Assess the wounds and provide care in a calm, nonjudgmental manner.
b. Ask the client what happened during the visit that triggered the behavior.
c. Remove the client’s unit privileges until safety is established.
d. Have the client sign a no-harm contract.
a. Assess the wounds and provide care in a calm, nonjudgmental manner.
A nurse is teaching the parents of an 8-year-old who will remain on a stimulant for several years. Which monitoring plan is BEST?
A. Serum drug levels each month to confirm the dose is therapeutic
B. Height, weight, blood pressure, and pulse at regular follow-up visits
C. An electrocardiogram at every visit
D. Liver function tests each month
B. Height, weight, blood pressure, and pulse at regular follow-up visits
A 6-year-old with autism spectrum disorder (ASD) is hospitalized after an appendectomy. When the IV pump alarms, the child covers both ears, rocks rapidly, and begins to scream. The parent is at the bedside. Which action by the nurse is BEST?
a. Ask the parent to step out briefly so the child can practice self-soothing.
b. Lower the room lighting and silence nonessential alarms and equipment noise.
c. Explain to the child what the pump does and why it makes noise.
d. Notify the provider to request a PRN medication for anxiety.
b. Lower the room lighting and silence nonessential alarms and equipment noise.
An 82-year-old client, 3 days post hip replacement, was oriented yesterday. Tonight the client is picking at the air, calling the nurse by a daughter's name, and cannot follow a conversation. Symptoms were minimal this afternoon. Which action should the nurse take first?
a. Apply soft wrist restraints to protect the surgical site
b. Orient the client to date, time, and place using the whiteboard
c. Obtain vital signs, pulse oximetry, and blood glucose
d. Request a PRN antipsychotic from the provider
c. Obtain vital signs, pulse oximetry, and blood glucose
A 72-year-old man, widowed 3 months ago, is brought in by his son for "memory loss." The client states, "My memory is gone, I'm useless." He answers most orientation questions with "I don't know" and makes little effort. He reports early-morning waking, a 12-lb weight loss, and loss of interest in his garden. Symptoms started about 6 weeks ago. Which finding BEST supports depression over dementia?
a. Weight loss and early morning waking
b. Loss of interest in a former hobby
c. “I don’t know” answers and minimal effort on testing
d. Difficulty recalling recent events
c. “I don’t know” answers and minimal effort on testing
A 45-year-old client is brought in by his sister. He lives alone, stocks shelves on the night shift, and says, “I’m fine on my own. I’ve never wanted a partner or close friends.” His speech is clear and logical, he reports no unusual beliefs or perceptual experiences, and he shows little emotional reaction when praised or criticized. Which disorder is MOST consistent with this presentation?
A. Antisocial personality disorder
B. Schizotypal personality disorder
C. Avoidant personality disorder
D. Schizoid personality disorder
D. Schizoid personality disorder
A 16-year-old with ADHD has a history of misusing a friend’s prescribed pills, and the family is concerned about diversion. Which medication does the nurse anticipate the provider will MOST likely consider?
A. Dextroamphetamine
B. Methylphenidate transdermal patch
C. Atomoxetine
D. Lisdexamfetamine
C. Atomoxetine
Dextroamphetamine, Methylphenidate (ritalin), and Lisdexamfetamine (Vyvanse) are controlled substances. Atomoxetine is a non-stimulant and is not a controlled substance
At an 18-month well-child visit, a parent tells the nurse that the toddler rarely turns when called by name, does not point to show things, and seldom makes eye contact. The toddler has about ten words. Which action by the nurse is BEST?
a. Reassure the parent that language development varies widely at this age.
b. Reassess at the 24-month visit, since a diagnosis cannot be made before age 2.
c. Facilitate referral for developmental evaluation along with a hearing assessment.
d. Teach the parent strategies to encourage speech and recheck in six months.
c. Facilitate referral for developmental evaluation along with a hearing assessment.
A client with delirium is being cared for on a medical unit. Which intervention is BEST for helping the client stay oriented?
A. Keep the room dim and the door closed throughout the day and night.
B. Place a clock and calendar within view and have familiar items from home at the bedside.
C. Rotate staff assignments each shift to provide new faces and stimulation.
D. Move the client to a different room if the confusion worsens.
B. Place a clock and calendar within view and have familiar items from home at the bedside.
Which nursing interventions are best for promoting safety in a client with Alzheimer’s disease who wanders?
Provide a safe, enclosed area for walking and have the client wear an identification bracelet
A nurse is comparing obsessive-compulsive personality disorder (OCPD) with obsessive-compulsive disorder (OCD). Which finding BEST distinguishes OCPD?
a. The client reports recurrent, intrusive thoughts that are difficult to dismiss.
b. The client views the rigid habits as sensible and the way things should be done.
c. The client performs repetitive rituals to reduce anxiety.
d. The client’s behaviors consume significant time and interfere with work.
b. The client views the rigid habits as sensible and the way things should be done.
What are side effects of adderall, and what are interventions to teach to manage the side effects better? Which ones would require intervention?
1. Decreased appetite - take in the morning AFTER breakfast, snack throughout the day
2. Insomnia - time dosing so that it's in the early morning and don't take additional dose after around 2 pm (depending on personal bedtime)
3. Dry mouth - gum, sugarless candies, frequent sips of water
4. Drug tolerance - take a "drug holiday" to reset physical tolerance
Rapid heart beat, hypertension, or circulatory issues.
Adderall can also cause increased urine output, severe anxiety, hallucination or paranoia and risk for misuse.
The parents of a 3-year-old who was recently diagnosed with ASD ask the nurse, “Will he grow out of this?” Which response by the nurse is BEST?
A. “Many children no longer meet the criteria by the time they start school.”
B. “Autism is lifelong, and early, intensive support can greatly improve communication and daily skills.”
C. “Outcomes do not change much regardless of the treatment you choose.”
D. “It’s too early to discuss the long-term picture until he has been in therapy for a year.”
B. “Autism is lifelong, and early, intensive support can greatly improve communication and daily skills.”
A client with delirium points to the wall and says, “There are snakes crawling down there!” Which response by the nurse is BEST?
A. “There are no snakes. You’re imagining things.”
B. “I don’t see any snakes, but I can tell you’re scared. I’m staying right here with you.”
C. “I see them too. I’ll get them out of here.”
D. “Tell me why you think snakes would be in the hospital.”
B. “I don’t see any snakes, but I can tell you’re scared. I’m staying right here with you.”
A nurse is assisting a client with moderate Alzheimer’s disease to get dressed. Which approach is BEST?
A. Lay out all of the clothing in the closet and ask the client to choose
B. Hand the client one item at a time and give simple, one-step instructions
C. Dress the client completely to save time
D. Explain each step of dressing before starting
B. Hand the client one item at a time and give simple, one-step instructions
A 29-year-old man is assessed for long-standing social isolation. He has no close friends, prefers working alone at night, and shows a flat affect and little response to praise or criticism. He also lines up objects in a set order, becomes very distressed if his commute route changes, covers his ears in loud places, and gives literal answers to figurative questions. His mother reports he did not speak in sentences until age 4. Which of the following disorder is most likely?
a. Obsessive-Compulsive Personality Disorder
b. Autism Spectrum Disorder
c. Schizoid personality Disorder
d. Antisocial Personality Disorder
b. Autism Spectrum Disorder
What non-pharmacological treatment is commonly used for treating ADHD?
Cognitive behavioral therapy (CBT)
A child with ASD has been taking risperidone for severe irritability. The parent calls the clinic nurse to report several new findings. Which finding requires the nurse’s IMMEDIATE attention?
A. The child has gained 3 pounds over the past month.
B. The child seems sleepy during the first week of each dose increase.
C. The child has a temperature of 39.4°C (103°F), stiff muscles, and heavy sweating.
D. The child seems unable to sit still and paces constantly.
C. The child has a temperature of 39.4°C (103°F), stiff muscles, and heavy sweating.