C HAPTER 23: N EUROCOGNITIVE D ISORDERS
Halter: Varcarolis’ Foundations of Psychiatric -Mental Health Nursing: A
Clinical Approach, 9th Edition
MULTIPLE CHOICE
1. An older adult client in the intensive care unit is experiencing visual
illusions. Which intervention will be most helpful?
a. Appl y the client’s glasses.
b. Place personall y meaningful objects in view.
c. Position large clocks and calendars on the wall.
d. Assure that the room is brightl y lit but very quiet at all times.
ANS: A
Illusions are sensory misperceptions. Glasses and hearing aids help
clarify sensory perceptions. Without glasses, clocks, calendars, and
personal objects are meaningless. Round - the-clock lighting promotes
sensory overload and sensory perceptual alterations.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
TOP: Nursing Process: Implementation MSC: Client
Needs: Psychosocial Integrit y
2. A client diagnosed with Alzheimer’s disease calls the fire department
saying, “My smoke detectors are going off.” Firefighters inv estigate and
discover that the client misinterpreted the telephone ringing. Which
problem is this client experiencing?
, a. Hyperoralit y
b. Aphasia
c. Apraxia
d. Agnosia
ANS: D
Agnosia is the inabilit y to recognize familiar objects, parts of one’s
body, or one’s own r eflection in a mirror. Hyperoralit y refers to
placing objects in the mouth. Aphasia refers to the loss of language
abilit y. Apraxia refers to the loss of purposeful movements, such as
being unable to dress.
PTS: 1 DIF: Cognitive Level: Understand (Comp rehension)
TOP: Nursing Process: Assessment MSC: Client Needs:
Psychosocial Integrity
3. During morning care, a nurse asks a client diagnosed with dementia, “How
was your night?” The client replies, “It was lovel y. I went out to dinner
and a movie with m y friend.” Which term applies to the client’s response?
a. Sundown syndrome
b. Confabulation
c. Perseveration
d. Delirium
ANS: B
Confabulation refers to making up of stories or answers to questions by
a person who does not remember. It is a defensive tactic to protect
self-esteem and prevent others from noticing memory loss. The client’s
, response was not sundown syndrome. Perseveration refers to repeating
a word or phrase over and over. Delirium is not present in this
scenario.
PTS: 1 DIF: Cognitive Level: Understa nd (Comprehension)
TOP: Nursing Process: Assessment MSC: Client Needs:
Psychosocial Integrity
4. A nurse counsels the famil y of a client diagnosed with Alzheimer’s
disease who lives at home and wanders at night. Which action is most
important for the nurse to recommend for enhancing safet y?
a. Appl y a medical alert bracelet to the client.
b. Place locks at the tops of doors.
c. Discourage daytime napping.
d. Obtain a bed with side rails.
ANS: B
Placing door locks at the top of the door makes it more difficult for the
client with dementia to unlock the door because the abilit y to look up
and reach upward is diminished. The client will try to climb over side
rails, increasing the risk for injury and falls. Avoiding daytime naps
may improve the client’s sleep pattern but does not assure safety. A
medical alert bracelet will be helpful if the client leaves the home, but
it does not prevent wandering or assure the client’s safet y.
PTS: 1 DIF: Cognitive Level: Anal yze (Anal ysis) TOP:
Nursing Process: Planning MSC: Client Needs: Safe,
Effective Care Environment
Halter: Varcarolis’ Foundations of Psychiatric -Mental Health Nursing: A
Clinical Approach, 9th Edition
MULTIPLE CHOICE
1. An older adult client in the intensive care unit is experiencing visual
illusions. Which intervention will be most helpful?
a. Appl y the client’s glasses.
b. Place personall y meaningful objects in view.
c. Position large clocks and calendars on the wall.
d. Assure that the room is brightl y lit but very quiet at all times.
ANS: A
Illusions are sensory misperceptions. Glasses and hearing aids help
clarify sensory perceptions. Without glasses, clocks, calendars, and
personal objects are meaningless. Round - the-clock lighting promotes
sensory overload and sensory perceptual alterations.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
TOP: Nursing Process: Implementation MSC: Client
Needs: Psychosocial Integrit y
2. A client diagnosed with Alzheimer’s disease calls the fire department
saying, “My smoke detectors are going off.” Firefighters inv estigate and
discover that the client misinterpreted the telephone ringing. Which
problem is this client experiencing?
, a. Hyperoralit y
b. Aphasia
c. Apraxia
d. Agnosia
ANS: D
Agnosia is the inabilit y to recognize familiar objects, parts of one’s
body, or one’s own r eflection in a mirror. Hyperoralit y refers to
placing objects in the mouth. Aphasia refers to the loss of language
abilit y. Apraxia refers to the loss of purposeful movements, such as
being unable to dress.
PTS: 1 DIF: Cognitive Level: Understand (Comp rehension)
TOP: Nursing Process: Assessment MSC: Client Needs:
Psychosocial Integrity
3. During morning care, a nurse asks a client diagnosed with dementia, “How
was your night?” The client replies, “It was lovel y. I went out to dinner
and a movie with m y friend.” Which term applies to the client’s response?
a. Sundown syndrome
b. Confabulation
c. Perseveration
d. Delirium
ANS: B
Confabulation refers to making up of stories or answers to questions by
a person who does not remember. It is a defensive tactic to protect
self-esteem and prevent others from noticing memory loss. The client’s
, response was not sundown syndrome. Perseveration refers to repeating
a word or phrase over and over. Delirium is not present in this
scenario.
PTS: 1 DIF: Cognitive Level: Understa nd (Comprehension)
TOP: Nursing Process: Assessment MSC: Client Needs:
Psychosocial Integrity
4. A nurse counsels the famil y of a client diagnosed with Alzheimer’s
disease who lives at home and wanders at night. Which action is most
important for the nurse to recommend for enhancing safet y?
a. Appl y a medical alert bracelet to the client.
b. Place locks at the tops of doors.
c. Discourage daytime napping.
d. Obtain a bed with side rails.
ANS: B
Placing door locks at the top of the door makes it more difficult for the
client with dementia to unlock the door because the abilit y to look up
and reach upward is diminished. The client will try to climb over side
rails, increasing the risk for injury and falls. Avoiding daytime naps
may improve the client’s sleep pattern but does not assure safety. A
medical alert bracelet will be helpful if the client leaves the home, but
it does not prevent wandering or assure the client’s safet y.
PTS: 1 DIF: Cognitive Level: Anal yze (Anal ysis) TOP:
Nursing Process: Planning MSC: Client Needs: Safe,
Effective Care Environment
