A nurse is caring for a group of older adult clients. Which of the following manifestations in-
dicates one of the clients is experiencing delirium?
A. A client wants to know the current time while there is a clock on the wall.
B. A client attempts to climb out of bed and repeatedly states she must get home.
C. A client requests extra blankets when the thermostat in the room indicates 25.6 Degrees
C (78 F).
D. A client refuses to get out of bed and has no motivation to attend to daily hygiene. - AN-
SWER B.
(Delirium is characterized by a change in cognition that occurs over a short period of time. It
results from a secondary physiological condition (e.g., infection, surgery, prolonged hospitali-
zation, hypoxia, fever, medications) and is a transient disorder. Although delirium can occur
with any age, it is more common in older adults. It frequently progresses in the evening
hours and is sometimes called "sundown syndrome." Delirium is characterized by alterations
in memory, agitation, restlessness, illusions, or hallucinations. A client who becomes acutely
confused and agitated may be showing manifestations of delirium.)
A nurse is caring for a client who has dementia. When performing a Mental Status Examina-
tion (MSE) the nurse should include which of the following data? (Select all that apply.)
A. Ability to perform calculations
B. Level of consciousness
C. Recall ability
D. Long-term memory
E. Level of orientation - ANSWER A, C, E.
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,(Evaluating the client's ability to perform calculations is an included component of an MSE.
Determining the client's level of consciousness is not a component of an MSE. Identifying
the client's ability to recall a list of objects or words is an included component of an MSE.
Evaluating long-term memory is not a component of an MSE. Determining the client's level
of orientation is an included component of an MSE.)
A community health nurse is providing teaching to the family of a client who has primary de-
mentia. Which of the following manifestations should the nurse tell the family to expect?
A. Decreased auditory and visual acuity.
B. Decreased display of emotion.
C. Personality traits that are opposite of original traits.
D. Forgetfulness gradually progressing to disorientation. - ANSWER D.
(Dementia usually appears first as forgetfulness. Other manifestations may be apparent only
upon neurologic examination or cognitive testing. Loss of functioning progresses slowly from
impaired language skills and difficulty with ordinary daily activities to severe memory loss
and complete disorientation with withdrawal from social interaction.)
A nurse is caring for a client who has dementia due to Alzheimer's disease and was admitted
to a long-term care facility following the death of her partner of 40 years. The client states, "
I want to go home; my husband is waiting for me to cook dinner. "Which of the following re-
sponses by the nurse is appropriate?
A. " this is where you live now."
B. " this is a safer place for you to live."
C. "Tell me what you like to cook for dinner."
D. "Your family said there is no one to care for you at home." - ANSWER C.
(Alzheimer's disease is a progressive cognitive disorder. Dementia due to Alzheimer's disease
means that the client is experiencing the later stages of the illness with moderately severe to
severe cognitive decline. By asking the client to talk about what she likes to cook for dinner,
2
, the nurse is demonstrating validation therapy by asking the client to talk about the areas
that concerned her. The nurse could continue the conversation by discussing how much the
client misses her home and partner. Validation therapy helps clients who have cognitive dis-
orders discuss their feelings about past events and people.)
A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's
disease. Which of the following interventions should the nurse include in the plan?
A. rotate assignment of daily caregivers.
B. provide an activity schedule that changes from day to day.
C. limit time for the client to perform activities.
D. talk the client through tasks one step at a time. - ANSWER D
(The nurse should plan to talk the client through tasks one step at a time to minimize confu-
sion and promote independence, which will decrease the client's anxiety level.)
The family of an older adult client brings him to the emergency department after finding him
wandering outside. During the initial assessment, the nurse notes that the client flinches
when she palpates his abdomen yet response to questions only by nodding and smiling.
Which of the following factors should the nurse identify as a likely explanation for the clients
behavior?
A. he is hard of hearing
B. pain
C. confusion
D. language barrier - ANSWER C
(since the client was manifesting signs of confusion before coming to the emergency depart-
ment and currently seems unable to understand or respond to speech, the nurse should de-
termine that the client has confusion)
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dicates one of the clients is experiencing delirium?
A. A client wants to know the current time while there is a clock on the wall.
B. A client attempts to climb out of bed and repeatedly states she must get home.
C. A client requests extra blankets when the thermostat in the room indicates 25.6 Degrees
C (78 F).
D. A client refuses to get out of bed and has no motivation to attend to daily hygiene. - AN-
SWER B.
(Delirium is characterized by a change in cognition that occurs over a short period of time. It
results from a secondary physiological condition (e.g., infection, surgery, prolonged hospitali-
zation, hypoxia, fever, medications) and is a transient disorder. Although delirium can occur
with any age, it is more common in older adults. It frequently progresses in the evening
hours and is sometimes called "sundown syndrome." Delirium is characterized by alterations
in memory, agitation, restlessness, illusions, or hallucinations. A client who becomes acutely
confused and agitated may be showing manifestations of delirium.)
A nurse is caring for a client who has dementia. When performing a Mental Status Examina-
tion (MSE) the nurse should include which of the following data? (Select all that apply.)
A. Ability to perform calculations
B. Level of consciousness
C. Recall ability
D. Long-term memory
E. Level of orientation - ANSWER A, C, E.
1
,(Evaluating the client's ability to perform calculations is an included component of an MSE.
Determining the client's level of consciousness is not a component of an MSE. Identifying
the client's ability to recall a list of objects or words is an included component of an MSE.
Evaluating long-term memory is not a component of an MSE. Determining the client's level
of orientation is an included component of an MSE.)
A community health nurse is providing teaching to the family of a client who has primary de-
mentia. Which of the following manifestations should the nurse tell the family to expect?
A. Decreased auditory and visual acuity.
B. Decreased display of emotion.
C. Personality traits that are opposite of original traits.
D. Forgetfulness gradually progressing to disorientation. - ANSWER D.
(Dementia usually appears first as forgetfulness. Other manifestations may be apparent only
upon neurologic examination or cognitive testing. Loss of functioning progresses slowly from
impaired language skills and difficulty with ordinary daily activities to severe memory loss
and complete disorientation with withdrawal from social interaction.)
A nurse is caring for a client who has dementia due to Alzheimer's disease and was admitted
to a long-term care facility following the death of her partner of 40 years. The client states, "
I want to go home; my husband is waiting for me to cook dinner. "Which of the following re-
sponses by the nurse is appropriate?
A. " this is where you live now."
B. " this is a safer place for you to live."
C. "Tell me what you like to cook for dinner."
D. "Your family said there is no one to care for you at home." - ANSWER C.
(Alzheimer's disease is a progressive cognitive disorder. Dementia due to Alzheimer's disease
means that the client is experiencing the later stages of the illness with moderately severe to
severe cognitive decline. By asking the client to talk about what she likes to cook for dinner,
2
, the nurse is demonstrating validation therapy by asking the client to talk about the areas
that concerned her. The nurse could continue the conversation by discussing how much the
client misses her home and partner. Validation therapy helps clients who have cognitive dis-
orders discuss their feelings about past events and people.)
A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's
disease. Which of the following interventions should the nurse include in the plan?
A. rotate assignment of daily caregivers.
B. provide an activity schedule that changes from day to day.
C. limit time for the client to perform activities.
D. talk the client through tasks one step at a time. - ANSWER D
(The nurse should plan to talk the client through tasks one step at a time to minimize confu-
sion and promote independence, which will decrease the client's anxiety level.)
The family of an older adult client brings him to the emergency department after finding him
wandering outside. During the initial assessment, the nurse notes that the client flinches
when she palpates his abdomen yet response to questions only by nodding and smiling.
Which of the following factors should the nurse identify as a likely explanation for the clients
behavior?
A. he is hard of hearing
B. pain
C. confusion
D. language barrier - ANSWER C
(since the client was manifesting signs of confusion before coming to the emergency depart-
ment and currently seems unable to understand or respond to speech, the nurse should de-
termine that the client has confusion)
3
