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The nurse is managing the care of a client diagnosed with dementia. The client experiences impulsive and aggressive behavior. Which intervention would the nurse include in the plan of care to address this behavior?
A. Regularly reevaluating the client's current level of functioning
B. Encouraging reminiscing by asking questions about the client's past
C. Keeping the client's daily routine simple and consistent
D. Planning sufficient time for the client to complete tasks
Answer: C
Rationale: With the assistance of caregivers and nursing personnel in controlling the environment, the person is helped to control the impulsive aggressive actions precipitated by frustration and confusion. Reassurance and calm are encouraged by consistency and simple, routine day-to-day activities. Reevaluating level of function and providing sufficient time for the completion of tasks encourage the client to be as independent as possible. Encouraging reminiscing is a strategy that supports memory.
A client is diagnosed with Lewy body disease When reviewing the care plan, the nurse should expect to see which area as a focus for nursing care?
A. Risk for violence risk related to agitation
B. Disturbed self-esteem related to hopelessness
C. Risk for injury related to shuffling gait
D. Impaired thought processes related to delusions
Answer: C
Rationale: Parkinson-like symptoms of slow, rigid movements and shuffling gait are seen in Lewy body dementia. The client with Lewy body disease typically experiences visual hallucinations, not delusions. Mental alertness is intermittent with the individual seemingly lucid one day, and confused, lethargic, distracted, and semiresponsive to the environment the next. The other options are not specific to this type of dementia.
The nurse observes an older adult client diagnosed with Alzheimer disease brushing their hair with a toothbrush. The nurse documents this behavior using which term?
A. Anomia
B. Agnosia
C. Aphasia
D. Apraxia
Answer: B
Rationale: Agnosia is the inability to identify an object. For example, the client may try to eat soup with a knife, eat the paper wrapper on a piece of candy, or attempt to shave with a toothbrush and toothpaste. This can also be sensory, such as the inability to identify hot temperature (e.g., the client may not realize their bath water is too hot and may burn themselves) or recognize the meaning of traffic lights. Anomia is the inability to find the right word. Aphasia is the impairment in the significance or meaning of language that prevents the person from understanding what is heard, following instructions, and communicating needs. Apraxia occurs when the person is unable to carry out purposeful movements and actions despite intact motor and sensory functioning.
In completing nursing care for an older client diagnosed with dementia, which intervention would be therapeutic for this individual?
A. Providing continuous stimuli to keep the client's attention
B. Using simple one-step commands to minimize frustration
C. Providing for higher-level needs to be met first
D. Allowing for flexibility in the daily schedule to provide varied experiences
Answer: B
Rationale: Using simple one-step commands would be appropriate since dementia tends to decrease the individual's ability to handle frustration that arises from confused thought processes. Basic needs must be met. Low levels of stimulation and a predictable schedule also assist in minimizing frustration and confusion.
A nurse suspects that a client is experiencing delirium. Which finding would support the nurse’s suspicion?
A. Confabulation
B. Gait disturbances
C. Fluctuation of symptoms
D. Visual hallucinations of colors
Answer: C
Rationale: A person diagnosed with delirium would be expected to exhibit symptoms that may fluctuate depending on the time of day. Persons with Alzheimer dementia may exhibit confabulation. Gait disturbances are seen in persons diagnosed with vascular dementia. Visual hallucinations occur in persons diagnosed with Lewy body dementia.
A spouse of a client newly diagnosed with dementia voices concern to the nurse, stating, “My spouse has started lying to me.” Which response would be most effective in addressing the spouse’s concern?
A. “The lying is a result of various personality changes caused by the disorder.”
B. “Your spouse isn't consciously lying but resorting to storytelling to make up for memory losses.”
C. “The lying is due to your spouse’s remaining thought processes capable of producing only fictitious thinking.”
D. “Your spouse is compensating for memory loss with a process called confabulation to fill in the gaps.”
Answer: D
Rationale: Early in the course of the disease, clients are usually aware of their memory deficit and try to compensate for their losses by using confabulation (filling in the gaps with fictitious statements). While the other options present true statements, they are not effective in addressing the spouse's expressed concerns.
A client is admitted to the inpatient mental health unit with Lewy body dementia. Which assessment finding would be most important for the nurse to note?
A. Hemiplegia
B. Parkinson-like symptoms
C. Increased psychomotor activity
D. Confabulation
Answer: B
Rationale: In the client diagnosed with Lewy body dementia, it would be important to observe for Parkinson-like symptoms, such as slow, rigid movements and a shuffling gait. Hemiplegia is seen in clients diagnosed with vascular dementia. A symptom associated with delirium is increased psychomotor activity. Confabulation occurs in persons diagnosed with amnestic disorders.
An older adult diagnosed with dementia is receiving risperidone. The nurse identifies this medication as belonging to which classification?
A. Antiparkinsonian agent
B. Antipsychotic
C. NMDA receptor antagonist
D. Cholinesterase inhibitor
Answer: B
Rationale: Risperidone is classified as an antipsychotic medication. An example of an antiparkinsonian agent is benztropine. An NMDA receptor antagonist is memantine, while galantamine, donepezil, and rivastigmine are examples of cholinesterase inhibitors.
A client diagnosed with Alzheimer dementia is experiencing impaired language and judgment. When explaining to the client’s family about these signs and symptoms, the nurse would describe which area of the brain as being affected?
A. Hippocampus
B. Cerebral cortex
C. Temporal lobe
D. Basal ganglia
Answer: B
Rationale: Once the disease progresses to the cerebral cortex, it begins to take away language and impairs judgment. As the neurons of the hippocampus degenerate, short-term memory fails. The ability to perform routine tasks begins to diminish. The temporal lobe is associated with vision and memory, while basal ganglia play a role in motor function.
The nurse is reviewing a care plan for a client diagnosed with dementia. The health care provider has prescribed haloperidol. The nurse determines that this treatment is effective based on which outcome?
A. Decreased Parkinson-like symptoms
B. Decreased depressive symptoms
C. Decreased physical aggressiveness
D. Decreased blood sugar levels
Answer: C
Rationale: Haloperidol is effective when the client experiences decreased verbal and physical aggression. An outcome of an antiparkinsonian mediation is decreased Parkinson-like symptoms. Antidepressants function to decrease depression. Insulin and antidiabetic medications function to decrease blood sugar levels.
A client is experiencing acute delirium. Which intervention would the nurse identify as the priority for this client?
A. Reducing environmental noise.
B. Initiating safety precautions.
C. Reorienting client to date, time, and place.
D. Explaining all procedures and events to client.
Answer: B
Rationale: Delirium is characterized by a disturbance of consciousness and a change in cognition that places the client at risk for a variety of safety-related injuries. The priority nursing intervention would be to maintain client safety by initiating safety precautions. Additional interventions specific to the client diagnosed with delirium include reducing environmental noise; reorienting the client to date, time, and place; and explaining all procedures and what is happening to the client.
When gathering data from an older adult client, which parameter would a nurse identify as an effect of secondary aging?
A. Stature
B. Race
C. Life experiences
D. Intelligence
Answer: C
Rationale: An effect of secondary aging includes those changes that are influenced by the environment, such as life experiences. The effects of primary aging are those changes that occur as a result of genetics or natural factors, such as stature, race, and intelligence.
A person tells the nurse, “See, look over there. There are monkeys in the corner of my room.” The nurse, suspecting the client is experiencing delirium, would document the client’s statement, describing it using which term?
A. Hallucination
B. Delusion
C. Illusion
D. Echolalia
Answer: A
Rationale: The person diagnosed with delirium may experience hallucinations and delusional thought processes. A hallucination is a false sensory perception unrelated to actual external stimuli. A delusion is a fixed, false belief without appropriate external stimuli that is inconsistent with reality and the person's own knowledge or experience. An illusion is a mental misinterpretation of actual sensory stimuli. Echolalia is an involuntary parrot-like repetition of words spoken by others, often accompanied by twitching of muscles.
An older adult has been prescribed donepezil for symptoms associated with dementia. Which statement made by the client's spouse identifies a need for further education concerning the expected effects of the medication?
A. “I'm anxious to see an improvement in the behavioral problems that exist.”
B. “This medication should help lessen the depression that has occurred.”
C. “Being more alert will allow us to enjoy watching television together again.”
D. “I'm hoping there will be fewer memory problems than before.”
Answer: B
Rationale: The cholinesterase inhibitors like donepezil are useful in increasing the levels of neurotransmitters or chemical messengers to the portions of the brain affected by Alzheimer disease. They can improve mental alertness and cognition, along with reducing behavioral problems. Thus, it is possible to see an improvement in behavior, alertness, and memory. This classification of medication is not prescribed for the treatment of depression.
A nurse is conducting a class for caregivers of clients diagnosed with Alzheimer disease. When describing the physiologic changes that are associated with this condition, which change(s) would the nurse likely include? Select all that apply.
A. Neurofibrillary tangles
B. Reduced brain activity
C. Neuritic plaques in the brain
D. Increased synaptic nerve transmission
E. Increased neuron generation in hippocampus
Answer: A, B, C
Rationale: A diagnosis of Alzheimer disease is made when the client has dense deposits, or neuritic plaques, outside and around the nerve cells in the brain and twisted strands of fiber, or neurofibrillary tangles. In regions attacked by the disease, the neurons degenerate and lose their synaptic connections to other neurons. PET scans show decreased brain activity in the brain of a person with Alzheimer disease. Today, a definite diagnosis of Alzheimer disease is still only possible when an autopsy shows these classic signs of the disease.
The nurse is reviewing a care plan for a client diagnosed with Alzheimer disease who is receiving antipsychotic medication. Which are the expected outcome(s) for this medication therapy? Select all that apply.
A. Decrease in muscle rigidity
B. Decrease in hallucinations
C. Increase in ability to acquire new information
D. Increase in mobility
E. Reduce verbal aggressiveness
Answer: B, E
Rationale: Antipsychotic medications are used in the treatment of dementia to decrease verbal and physical aggressiveness as well as hallucinations and delusions. They do not decrease muscle rigidity, increase the ability to acquire new information, or increase mobility.
The nurse is reviewing the discharge education for the family of an older client who was hospitalized for treatment of delirium. Which information should the nurse reinforce to minimize the future risk of developing delirium again? Select all that apply.
A. Check with the client's health care provider before introducing any new medications.
B. Assure that the client has a consistent, predictable daily routine.
C. Know characteristic signs and symptoms of infection in the older population.
D. Help assure the client maintains an adequate fluid intake to remain well hydrated.
E. Be familiar with the adverse reactions for all the medications the client is prescribed.
Answer: A, C, D, E
Rationale: Older adults are more at risk for delirium because of their higher incidence of chronic illness and their use of multiple medications to manage those disorders. The increased chance of hospitalization for acute infections, sepsis, and exacerbations of chronic illnesses such as heart failure and chronic pulmonary disease adds to the risk. The combined use of both prescription and over-the-counter medications can contribute to the development of delirium. Significant risk factors for delirium are the body's decreased ability to metabolize and excrete drugs as the body ages, making adverse drug reactions more common. In addition, nutritional or fluid deficiencies can contribute to the onset of a delirious state. The client experiencing dementia benefits from a consistent routine that minimizes the possibility of unexpected demands.
A client is diagnosed with severe Alzheimer disease. Which finding(s) would the nurse most likely expect to note? Select all that apply.
A. Poor short-term memory
B. Mild anomia
C. Wandering or pacing
D. Total loss of speech
E. Incontinence
Answer: D, E
Rationale: Severe Alzheimer disease is characterized by severe cognitive impairment, total loss of speech, loss of appetite, and incontinence. Poor short-term memory and mild anomia occur in mild Alzheimer disease. Wandering or pacing is seen in moderate Alzheimer disease.
The nurse is reviewing the medical records of several older clients who are experiencing delirium. Which condition(s) would the nurse identify as potential causes of this condition? Select all that apply.
A. Anxiolytic intoxication
B. Respiratory disorders
C. Renal disease
D. Alcohol intoxication
E. Dehydration
Answer: A, C, D, E
Rationale: Anxiolytic and alcohol intoxication are common causes of delirium in the older adult. Fluid and electrolyte imbalances commonly trigger delirium in that population. Renal disease is a medical condition related to the cause of delirium. Respiratory disorders are not directly associated with the development of delirium.
A nurse is conducting a presentation for a group of older adults and the importance of mental health treatment. The nurse asks the group, “What might interfere with getting the treatment that you need?” The nurse would likely hear the group identify which concern(s)? Select all that apply.
A. Fear of institutionalization
B. Limited personal income
C. Existing medical costs
D. Severe lack of mental health services
E. Reflection as a sign of personal weakness
Answer: A, B, C, E
Rationale: Mental health care costs, limited income, fear of institutionalization, and a perceived personal weakness are reasons that may decrease the chance that the older adult will seek treatment. While mental health services are not readily available as physical care services, they do exist and can be accessed.