Diagnosis Related
Disease process in which there is progressive decline in cognitive ability in the presence of clear consciousness. It involves many cognitive deficits and significantly impairs social and occupational functioning.
Dementia
An increase in agitation that occurs in the evening accompanied by confusion and is commonly seen in patients with dementia
What is sundowning?
At least two interventions/resources for those who have experienced sexual trauma
Psychotherapy
Crisis counseling—Includes referrals to a family physician, community psychologist, and rape crisis line.
Group therapy can be beneficial.
If SART is unavailable, provide information on support groups and attorneys
who work with survivors.
List of safe houses should also be available for those involved with intimate
partner violence (IPV).
Assess within 24 to 48 hours by telephone.
The nurse working in a long-term care facility knows that elder abuse most often consists of:
A. Financial exploitation.
B. Neglect.
C. Physical abuse.
D. Sexual abuse.
Answer: B.
Elder abuse mostly consists of neglect followed by physical abuse, financial or material exploitation, psychological or emotional abuse, and sexual abuse.
A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially?
1. Move the client next to the nurses’ station.
2. Use an indirect light source and turn off the television.
3. Keep the television and a soft light on during the night.
4. Play soft music during the night, and maintain a well-lit room.
Answer: 2
Rationale: Provision of a consistent daily routine and a low-stimulating environment is important when a client is disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses’ station may become necessary but is not the initial action.
Identify two positive symptoms of schizophrenia
What is..
Delusions
Paranoia
Magical Thinking
Loose Associations
Neologisms
Clang Associations
Word Salad
Tangentially
Preservation
Echolalia
Hallucinations
Illusions
Echopraxia
Term for a type of memory error in which gaps in a person's memory are unconsciously filled with fabricated, misinterpreted, or distorted information that the individual believes are true
Confabulation
Name of at least one "date rape drug"
Gamma-hydroxybutyric acid (GHB)
Rohypnol (flunitrazepam)
Ketamine
The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority information should be included in the discharge instructions?
1. Information regarding shelters
2. Instructions regarding calling the police
3. Instructions regarding self-defense classes
4. Explaining the importance of leaving the violent situation
Answer: 1
Rationale: Tertiary prevention of family violence includes assisting the victim after the abuse has already occurred. The nurse should provide the client with information regarding where to obtain help, including a specific plan for removing the self from the abuser and information regarding escape, hotlines, and the location of shelters. An abused person is usually reluctant to call the police. Teaching the victim to fight back is not the appropriate action for the victim when dealing with a violent person. Explaining the importance of leaving the violent situation is important, but a specific plan is necessary.
The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia?
1. Use of confabulation
2. Improvement in sleeping
3. Absence of sundown syndrome
4. Presence of personal hygienic care
Answer: 1
Rationale: The clinical picture of dementia ranges from mild cognitive deficits to severe, life-threatening alterations in neurological functioning. For the client to use confabulation or the fabrication of events or experiences to fill in memory gaps is not unusual. Often, lack of inhibitions on the part of the client may constitute the first indication of something being “wrong” to the client’s significant others (e.g., the client may undress in front of others, or the formerly well-mannered client may exhibit slovenly table manners). As the dementia progresses, the client will have difficulty sleeping and episodes of wandering or sundowning.
At least one cause of delirium
Substance Intoxication Delirium
Substance Withdrawal Delirium
Medications-Induced Delirium
Delirium d/t Another Medical Condition or to Multiple Etiologies
Difference between child neglect vs abuse
Abuse is certain behavior that harms the child and neglect is failure to provide the child with things that they need.
At least two nursing interventions to help the environment of someone experiencing delirium
Maintain a low level of stimuli in client’s environment (low lighting, few people, simple decor, low noise level) because anxiety increases in a highly stimulating environment.
Remove all potentially dangerous objects from client’s environment; in a disoriented, confused state, clients may use objects to harm self or others.
Ensuring adequate day time light is received.
Hearing aids, eyeglasses and other devices that assist sensory perception should be used whenever possible.
The home health-care nurse is caring for a client taking donepezil (Aricept). Which finding indicates the medication is effective?
1. The client is unable to relate his or her name or birth date.
2. The client is discussing an upcoming event with the family.
3. The client is wearing underwear on the outside of the clothes.
4. The client is talking on a telephone that is signaling a dial tone.
ANS: 2
Cholinesterase inhibitors are prescribed to increase cognitive ability for clients diagnosed with Alzheimer’s disease. Discussing an upcoming event indicates the client is able to focus on a topic and remember that something will happen in the future.
The nurse notes that a client with schizophrenia and receiving an antipsychotic medication is moving her mouth, protruding her tongue, and grimacing as she watches television. The nurse determines that the client is experiencing which medication complication?
1. Parkinsonism
2. Tardive dyskinesia
3. Hypertensive crisis
4. Neuroleptic malignant syndrome
Answer: 2
Rationale: Tardive dyskinesia is a reaction that can occur from antipsychotic medication. It is characterized by uncontrollable involuntary movements of the body and extremities, particularly the tongue. Parkinsonism is characterized by tremors, mask-like facies, rigidity, and a shuffling gait. Hypertensive crisis can occur from the use of monoamine oxidase inhibitors and is characterized by hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, and vomiting. Neuroleptic malignant syndrome is a potentially fatal syndrome that may occur at any time during therapy with neuroleptic (antipsychotic) medications. It is characterized by dyspnea or tachypnea, tachycardia or irregular pulse rate, fever, blood pressure changes, increased sweating, loss of bladder control, and skeletal muscle rigidity.
Difference in time of onset of delirium vs dementia
Delirium is sudden and dementia is slow
Term for the loss of ability to execute or carry out skilled movement and gestures, despite having the physical ability and desire to perform them
Apraxia
At least two education points to discuss with victims of domestic violence
Assist the victim to develop self-protective and other problem-solving abilities.
Even if the victim is not ready to leave the situation, encourage the victim to develop a specific safety plan (a fast escape if the violence returns) and provide information on where to obtain help (hotlines, safe houses, and shelters); an abused person is usually reluctant to call the police.
A patient with schizophrenia is exhibiting Parkinsonism symptoms. Which medication is responsible for the development of these symptoms?
1. olanzapine (Zyprexa)
2. benztropine (Cogentin)
3. diphenhydramine (Benadryl)
4. divalproex sodium (Depakote)
A potential side effect of antipsychotic medication is Parkinsonism symptoms
An elderly client with severe dementia is not able to communicate the most basic needs. How may the nurse improve the client’s comfort? Select all that apply.
A. Assess the client for pain on a regular basis.
B. Establish a toileting schedule for the client.
C. Increase observation of the client.
D. All four siderails engaged.
Answer: A, B, & C.
Establishing a toileting schedule, administering pain medication as scheduled or as needed, and increasing observation of the client can enhance healing and promote comfort. Having all four siderails engaged is considered a restraint and requires a physician order.
Name the four "A's" of Alzheimer's Disease
Agnosia: Failure to recognize or identify familiar objects despite intact sensory function
Amnesia: Loss of memory caused by brain degeneration
Aphasia: Language disturbance in understanding and expressing spoken words
Apraxia: Inability to perform motor activities, despite intact motor function
A condition in which a patient's limbs retain any position into which they are manipulated by another person and which occurs especially in catatonic schizophrenia.
What is waxy flexibility?
Name of at least one cholinesterase inhibitor used in treatment of cognitive impairment
Donepezil (Aricept)
Rivastigmine (Exelon)
Galantamine (Razadyne)
Clients diagnosed with Alzheimer’s disease respond to cholinergic medications. Why do these medications help these clients?
1. Cholinergics increase acetylcholine in the brain.
2. Parasympathetic stimulation helps the Alzheimer’s client to function at a higher level.
3. Sympathetic stimulation is inhibited when cholinergic medications are used.
4. The vasodilation caused by the cholinergics increases the amount of oxygen available.
Answer: A.
In Alzheimer’s disease, levels of acetylcholine (ACH) are decreased. When the medication binds with the cholinesterase enzyme, acetylcholine increases. Parasympathetic stimulation does not help the Alzheimer’s client. Sympathetic stimulation does not occur with these medications. Vasodilation occurs but does not impact the Alzheimer’s client.
Which statement is the scientific rationale for prescribing and administering donepezil (Aricept)?
1. Donepezil works to bind the dopamine at neuron receptor sites to increase ability.
2. Donepezil increases the availability of acetylcholine at cholinergic synapses.
3. Donepezil decreases acetylcholine in the periphery to increase movement.
4. Donepezil delays transmission of acetylcholine at the neuronal junction.
ANS: 2
Cholinesterase inhibitors increase the availability of acetylcholine at cholinergic synapses, resulting in increased transmission of acetylcholine by cholinergic neurons that have not been destroyed by the Alzheimer’s disease.