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Dementia and Delirium Exam Questions and answers with explanation. All You Need To Pass..Graded A+

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A health care team is involved in caring for a client with advanced Alzheimer's disease. During a team conference, a newly hired nurse indicates that she has never cared for a client with advanced Alz... heimer's disease. Which key point about the disease should the charge nurse include when teaching this nurse? The nursing staff should rely on the family to assist with care because family members know the client best. As long as the client receives the ordered medication, special care measures aren't necessary. Alzheimer's disease affects memory so the client doesn't need an explanation before procedures are performed. Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgment. - Ans-Correct response: Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgment. Explanation: The charge nurse should inform the new nurse that clients with Alzheimer's disease are at high risk for injury because they have impaired memory and poor judgment. Maintaining a safe environment takes top priority. Families are an important part of the client care team; however, they shouldn't be relied upon to deliver care. Family members may take turns sitting with the hospitalized client to help maintain client safety. All procedures should be explained in simple terms that the client can understand. Medications should be administered as ordered; however, they don't typically improve symptoms. Instead, they slow disease progression. A nurse is presenting a safety program to a group of older adults at a continuing care retirement community. The nurse emphasizes measures to reduce the risk of falls based on the understanding that which type of fracture is the most common? Femur Hip Ankle Forearm - Ans-Correct response: Hip Explanation: The most common fracture resulting from falls is hip fracture, which is linked to both osteoporosis and the situation that provoked the fall. Many older adults who fall and sustain a hip fracture cannot regrain their prefracture ability. The most common affective or mood disorder of old age is depression schizophrenia anxiety disorder phobias. - Ans-Correct response: depression. Explanation: Depression is the most common affective or mood disorder of old age. Anxiety disorders, schizophrenia, and phobias are not a common affective or mood disorder of old age. A client at an extended-care facilty who has Alzheimer's disease is awake throughout the night. The nurse intervenes with activities that will promote sleep at night, which include Walking the client in the facility yard during the day Providing a glass of warm milk for breakfast Having the client sit at the nurse's station during night-time hours Allowing the client to take a 2-hour nap in the afternoon - Ans-Correct response: Walking the client in the facility yard during the day Explanation: Regular exercise during the day will enhance sleep at night for clients with Alzheimer's disease. Another activity that helps for interrupted sleep, inability to fall asleep, or both is drinking warm milk at night. The nurse should discourage excessive sleep during the day. Sitting at the nurse's station may be too stimulating at night-time hours. A nurse is caring for an elderly adult client admitted to the hospital from a nursing home because of a change in behavior. The client has a diagnosis of Alzheimer's disease and has started to experience episodes of incontinence. The hospital staff is having difficulty with toileting because the client wanders around the unit all day. To assist with elimination, a nurse should: ask the physician to order sedation to allow the client to rest ask the physician to order restraints to prevent wandering incorporate the client's toileting schedule into the pattern of his wandering have the client wear two briefs at a time to ensure absorption of incontinent urine. - Ans-Correct response: incorporate the client's toileting schedule into the pattern of his wandering. Explanation: Incorporating the client's toileting schedule into his wandering assists with elimination and increases the chance of continent episodes. Sedation and restraints will decrease the client's mobility but won't decrease the number of incontinent episodes. Wearing two briefs at a time won't ensure urine absorption and won't address the incontinence issue. A client with Alzheimer's disease is admitted for hip surgery after falling and fracturing the right hip. The client's spouse tells the nurse about feeling guilty for letting the accident happen and reports not sleeping well lately because the spouse has been getting up at night and doing odd things. Which nursing diagnosis is most appropriate for the client's spouse? Defensive coping related to diagnosis of Alzheimer's disease Risk for caregiver role strain related to increased client care needs Decisional conflict related to lack of relevant treatment information Relocation stress syndrome related to hospitalization - Ans-Correct response: Risk for caregiver role strain related to increased client care needs Explanation: The client's spouse is at risk for caregiver role strain because the client has started to exhibit care needs beyond the spouse's capacity to provide. A diagnosis of Relocation stress syndrome may be appropriate for a client with inadequate preparation for hospital admission, transfer, or discharge; however, this client is confused and may be unable to grasp the meaning of such preparation. The spouse, on the other hand, is more likely to be relieved, at least physically, and able to rest because of the client's admission. Defensive coping and Decisional conflict aren't pertinent nursing diagnoses in this situation because the client's spouse is aware of and has accepted the client's disease. What is a nurse's role in providing home care for a client with Alzheimer disease? Provide assistance with administering IV fluids Support client with household errands Provide emotional and physical support Contact the Motor Vehicle Department to have driver's license revoked. - Ans-Correct response: Provide emotional and physical support. Explanation: Home health care nurses provide emotional support and intervene if family caregivers become overburdened. The nurse also instructs the family about physical care, the disease process, and treatment. Administering IV fluids or supporting clients with household errands is not a relevant role for a home nurse. The nurse should provide education about safety, saying that the client with Alzheimer disease should not drive, but contacting the licensing department is not the nurse's responsibility. Which condition is characterized by a decline in intellectual functioning? Dementia Depression Delirium Delusion - Ans-Correct response: Dementia Explanation: Dementia is an acquired syndrome in which progressive deterioration in global intellectual abilities is of such severity that it interferes with the person's customary occupational and social performance. Depression is a mood disorder that disrupts quality of life. Delirium is often called acute confusional state. Delusion is a symptom of psychoses. A family of a patient with Alzheimer's disease asks the nurse what causes this condition? Which response by the nurse would be most appropriate? "The numerous drugs that he was taking contributed to his current confusion." "A specific gene is involved in the development of this disorder." "Evidence shows that there are changes in nerve cells and brain chemicals." "This condition is most likely due to a stroke that the patient didn't realize he had." - Ans-Correct response: "Evidence shows that there are changes in nerve cells and brain chemicals." Explanation: Specific neuropathologic and biochemical changes are found in patients with Alzheimer's disease. These include neurofibrillary tanges and neuritic plaques as well as altered neurotransmitter function, specifically acetylcholine. Vascular dementia is associated with a subclinical stroke. Although genetics is being studied as an underlying mechanism for Alzheimer's disease, no specific gene or gentic marker has been identified. Delirium is often the result of the interaction or use of multiple drugs. The plan of care for a patient with advanced Alzheimer's disease includes the nursing diagnosis of risk for injury. The nurse has identified this nursing diagnosis most likely as related to which of the following? Personality changes Communication difficulties Separation from others Impaired memory - Ans-Correct response: Impaired memory Explanation: Patients with Alzheimer's disease are at high risk for injury because they have impaired memory and poor judgment. They also exhibit impulsivity, which increases their risk. Maintaining a safe environment takes top priority. Communication difficulties could be the basis for several nursing diagnoses such as impaired verbal communication, powerlessness, and impaired social interaction. Separation from others could lead to social isolation, impaired social interaction, and social isolation. Personality changes may lead to a risk for self- or other directed violence, chronic low self-esteem, and risk for suicide. Which neurotransmitter is implicated in depression? Epinephrine Acetylcholine Atropine Serotonin - Ans-Correct response: Serotonin Explanation: Serotonin is implicated in the development of depression. Atropine, acetylcholine, and epinephrine are not implicated in the development of depression. A client reports to the nurse that her elderly mother has become increasingly angry and responds inappropriately to conversations within the past few months. She notes that her mother does not respond when the mother's back is turned. The best intervention of the nurse is to Inform the client to ignore the behavior and the mother will stop. Tell the client it appears the mother has a hearing loss. Ask if the mother could come in for a hearing evaluation. Teach the client techniques for coping with the mother's anger. - Ans-Correct response: Ask if the mother could come in for a hearing evaluation. Explanation: The client's mother may be experiencing a hearing loss, and the mother should be evaluated for the symptoms the client has described. The other options do not facilitate assessment and, thus, treatment. A nurse is planning discharge teaching for an older adult client with mild short-term memory loss. The discharge teaching will include how to perform basic wound care for the venous ulcer on the client's lower leg. When planning the necessary health education for this client, the nurse should: keep visual cues to a minimum to enhance the client's focus set long-term goals with the client keep teaching periods short. provide a list of useful websites to supplement learning. - Ans-Correct response: keep teaching periods short. Explanation: To assist the elderly client with short-term memory loss, the nurse should keep teaching periods short, provide glare-free lighting, link new information with familiar information, use visual and auditory cues, and set short-term goals with the client. The client may or may not be open to the use of online resources. A client with moderate Alzheimer's disease has been eating poorly, losing weight, and playing with food at meals. The nurse best intervenes by Cutting the client's food into small pieces Converting liquid foods to a gelatin texture Serving hot foods at a warm temperature Placing one food at a time in front of the client during meals - Ans-Correct response: Placing one food at a time in front of the client during meals Explanation: Tasks should be simplified for the client with Alzheimer's disease. All options are steps the nurse can take to promote eating for the client with Alzheimer's disease. Offering one food at a time, however, helps to prevent the client from playing with food. To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should: give the client privacy during meals help the client fill out his menu fill out the menu for the client stay with the client and encourage him to eat - Ans-Correct response: stay with the client and encourage him to eat. Explanation: Staying with the client and encouraging him to feed himself will ensure adequate food intake. A client with Alzheimer's disease can forget how to eat. Allowing privacy during meals, filling out the menu, or helping the client to complete the menu doesn't ensure adequate nutritional intake. A nurse is caring for a client with dementia. A family member of the client asks what the most common cause of dementia is. Which response by the nurse is most appropriate? "Drug interactions are the most common cause of dementia in the elderly." "The most common cause of dementia in the elderly is Alzheimer's disease." "Depression may manifest as dementia in elderly clients." "Dementia is a terrible disease of the elderly." - Ans-Correct response: "The most common cause of dementia in the elderly is Alzheimer's disease." Explanation: The nurse should inform the family member that Alzheimer's disease is the most common cause of dementia in elderly clients. Dementia is a clinical manifestation, not a disease process. Although drug interactions and overmedication are causes of dementia, these causes aren't as common as Alzheimer's [Show More]

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