NCM114-RLE-AlzheimersDisease-2.
D. Loss of cognitive abilities, impairing ability to perform activities of daily living
A student nurse was asked which of the following best describes dementia. Which of the following
best describes the condition?
A. Memory loss occurring as part of the natural consequence of aging
B. Difficulty coping with physical and psychological change
C. Severe cognitive impairment that occurs rapidly
D. Loss of cognitive abilities, impairing ability to perform activities of daily living
D. Short words and simple sentences
Which of the following will Nurse Dory use when communicating with a client who has cognitive
impairment.
A. Complete explanations with multiple details
B. Pictures or gestures instead of words
C. Stimulating words and phrases to capture the client's attention
D. Short words and simple sentences
D. fills in memory gaps with fantasy.
Mrs. Mendoza is a 75-year-old client who has dementia of the Alzheimer's type and confabulates.
The nurse understands that this client:
A. Denies confusion by being jovial.
B. Pretends to be someone else.
C. Rationalizes various behaviors.
D. fills in memory gaps with fantasy.
B. Recalling past events
Which ability should Nurse Rebecca expect from a client in the mild stage of dementia of the
Alzheimer's type?
A. Remembering the daily schedule
B. Recalling past events
C. Coping the anxiety
D. Solving problems of daily living
B. "The changes in his behavior came on so quickly! I wasn't sure what was happening."
82-year-old Mr. Robeson together with his daughter arrived at the medical-surgical unit for
diagnostic confirmation and management of probable delirium. Which statement by the client's
daughter best supports the diagnosis?
A. "Maybe it's just caused by aging. This usually happens by age 82."
B. "The changes in his behavior came on so quickly! I wasn't sure what was happening."
C. "Dad just didn't seem to know what he was doing. He would forget what he had for breakfast."
D. "Dad has always been so independent. He's lived alone for years since mom died."
C. Remain calm and talk quietly to the client.
Mrs. Jordan is an elderly client diagnosed with Alzheimer's disease. She becomes agitated and
combative when a nurse approaches to help with morning care. The most appropriate nursing
intervention in this situation would be to:
,NCM114-RLE-AlzheimersDisease-2.
A. tell the client firmly that it is time to get dressed.
B. obtain assistance to restrain the client for safety.
C. remain calm and talk quietly to the client.
D. call the doctor and request an order for sedation.
B. The client will maintain safety.
Which goal is a priority for a client with a DSM-IV-TR diagnosis of delirium and the nursing diagnosis
Acute confusion related to recent surgery secondary to traumatic hip fracture?
A. The client will complete activities of daily living.
B. The client will maintain safety.
C. The client will remain oriented.
D. The client will understand communication.
C. Stimulating environment
Which of the following is not included in the care of plan of a client with a moderate cognitive
impairment involving dementia of the Alzheimer's type?
A. Daily structured schedule
B. Positive reinforcement for performing activities of daily living
C. Stimulating environment
D. Use of validation techniques
C. Sundowning.
In clients with a cognitive impairment disorder, the phenomenon of increased confusion in the early
evening hours is called:
A. Aphasia.
B. Agnosia.
C. Sundowning.
D. Confabulation.
D. The client will follow an established schedule for activities of daily living.
Which of the following outcome criteria is appropriate for the client with dementia?
A. The client will return to an adequate level of self-functioning.
B. The client will learn new coping mechanisms to handle anxiety.
C. The client will seek out resources in the community for support.
D. The client will follow an established schedule for activities of daily living.
D. Validation techniques
During the home visit of a client with dementia, the nurse notes that an adult daughter persistently
corrects her father's misperceptions of reality, even when the father becomes upset and anxious.
Which intervention should the nurse teach the caregiver?
A. Anxiety-reducing measures
B. Positive reinforcement
C. Reality orientation techniques
D. Validation techniques
,NCM114-RLE-AlzheimersDisease-2.
A, C, and F
Mr. Lim who is diagnosed with moderate dementia has frequent catastrophic reactions during
shower time. Which of the following interventions should be implemented in the plan of care?
Select all that apply.
A. Assign consistent staff members to assist the client.
B. Accomplish the task quickly, with several staff members assisting.
C. Schedule the client's shower at the same time of day.
D. Sedate the client 30 minutes prior to showering.
E. Tell the client to remain calm while showering.
F. Use a calm, supportive, quiet manner when assisting the client.
1. Alzheimer disease is the most common form of which of these?
The correct answer is B. Dementia.
It is a collection of symptoms characterized by decreasing intellectual and social abilities.
2. How is Alzheimer disease diagnosed?
The correct answer is D. All of the above.
No single test identifies Alzheimer disease. Lab tests help rule out other disorders that may produce
similar symptoms. Neurological and mental-status tests reveal cognitive-function deficits.
3. Physiologically, what happens to the brain as Alzheimer disease progresses?
The correct answer is C. Many cells die.
Nerve cells change in certain parts of the brain, which causes brain cells to die. The loss of cells
impairs thinking and judgment.
4. Which of these is the strongest risk factor for developing the disease?
The correct answer is B. Age.
Although some studies have shown an association between certain modifiable lifestyle factors and a
reduced risk for Alzheimer disease, the National Institutes of Health says that age is the strongest
known risk factor where most people receive the diagnosis after age 60. An early onset familial form
can also occur, although it is rare.
5. Occasionally, other health conditions may mimic this disease. What are they?
The correct answer is D. All of the above.
Dementia can result from a variety of causes, but when Alzheimer is involved, dementia is
irreversible and progressive.
6. Signs of Alzheimer disease include which of these symptoms?
The correct answer is D. All of the above.
Alzheimer sufferers also can't learn new information and tend to repeat themselves.
7. Which age group has the highest rate of Alzheimer cases reported?
The correct answer is A. 85 and older.
8. Because no medicines cure this condition, emphasis is put on delaying the onset of severe
symptoms. Which of these strategies helps?
The correct answer is D. All of the above.
Help keep the person's body physically active and mind engaged as long as possible.
9. The average time from the onset of symptoms to death is how long?
The correct answer is B. 8 years.
Alzheimer patients may live as few as 3 years or as long as 20 years with the disease.
10. If you care for a relative with Alzheimer disease, which of these measures will help stabilize
the patient mentally?
The correct answer is C. Establish a regular routine.
, NCM114-RLE-AlzheimersDisease-2.
If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the
nurse would anticipate that the client has problems with:
A. body temperature control.
B. balance and equilibrium.
C. visual acuity.
D. thinking and reasoning
A
A female client admitted to an acute care facility after a car accident develops signs and symptoms
of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation
to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates
administering which drug endotracheally before suctioning?
A. phenytoin (Dilantin)
B. mannitol (Osmitrol)
C. lidocaine (Xylocaine)
D. furosemide (Lasix)
C
After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the
emergency department. He's unconscious and his pupils are nonreactive. Which intervention would
be the most dangerous for the client?
A. Give him a barbiturate.
B. Place him on mechanical ventilation.
C. Perform a lumbar puncture.
D. Elevate the head of his bed.
C
When obtaining the health history from a male client with retinal detachment, the nurse expects the
client to report:
A. light flashes and floaters in front of the eye.
B. a recent driving accident while changing lanes.
C. headaches, nausea, and redness of the eyes.
D. frequent episodes of double vision.
A
Which nursing diagnosis takes highest priority for a client with Parkinson's crisis?
a. Imbalanced nutrition: Less than body requirements
b. Ineffective airway clearance
c. Impaired urinary elimination
d. Risk for injury
B
To encourage adequate nutritional intake for a female client with Alzheimer's disease, the nurse
should:
a. stay with the client and encourage him to eat.
b. help the client fill out his menu.
c. give the client privacy during meals.
d. fill out the menu for the client.
A
The nurse is performing a mental status examination on a male client diagnosed with subdural
hematoma. This test assesses which of the following?
a. Cerebellar function
b. Intellectual function
c. Cerebral function
d. Sensory function
D. Loss of cognitive abilities, impairing ability to perform activities of daily living
A student nurse was asked which of the following best describes dementia. Which of the following
best describes the condition?
A. Memory loss occurring as part of the natural consequence of aging
B. Difficulty coping with physical and psychological change
C. Severe cognitive impairment that occurs rapidly
D. Loss of cognitive abilities, impairing ability to perform activities of daily living
D. Short words and simple sentences
Which of the following will Nurse Dory use when communicating with a client who has cognitive
impairment.
A. Complete explanations with multiple details
B. Pictures or gestures instead of words
C. Stimulating words and phrases to capture the client's attention
D. Short words and simple sentences
D. fills in memory gaps with fantasy.
Mrs. Mendoza is a 75-year-old client who has dementia of the Alzheimer's type and confabulates.
The nurse understands that this client:
A. Denies confusion by being jovial.
B. Pretends to be someone else.
C. Rationalizes various behaviors.
D. fills in memory gaps with fantasy.
B. Recalling past events
Which ability should Nurse Rebecca expect from a client in the mild stage of dementia of the
Alzheimer's type?
A. Remembering the daily schedule
B. Recalling past events
C. Coping the anxiety
D. Solving problems of daily living
B. "The changes in his behavior came on so quickly! I wasn't sure what was happening."
82-year-old Mr. Robeson together with his daughter arrived at the medical-surgical unit for
diagnostic confirmation and management of probable delirium. Which statement by the client's
daughter best supports the diagnosis?
A. "Maybe it's just caused by aging. This usually happens by age 82."
B. "The changes in his behavior came on so quickly! I wasn't sure what was happening."
C. "Dad just didn't seem to know what he was doing. He would forget what he had for breakfast."
D. "Dad has always been so independent. He's lived alone for years since mom died."
C. Remain calm and talk quietly to the client.
Mrs. Jordan is an elderly client diagnosed with Alzheimer's disease. She becomes agitated and
combative when a nurse approaches to help with morning care. The most appropriate nursing
intervention in this situation would be to:
,NCM114-RLE-AlzheimersDisease-2.
A. tell the client firmly that it is time to get dressed.
B. obtain assistance to restrain the client for safety.
C. remain calm and talk quietly to the client.
D. call the doctor and request an order for sedation.
B. The client will maintain safety.
Which goal is a priority for a client with a DSM-IV-TR diagnosis of delirium and the nursing diagnosis
Acute confusion related to recent surgery secondary to traumatic hip fracture?
A. The client will complete activities of daily living.
B. The client will maintain safety.
C. The client will remain oriented.
D. The client will understand communication.
C. Stimulating environment
Which of the following is not included in the care of plan of a client with a moderate cognitive
impairment involving dementia of the Alzheimer's type?
A. Daily structured schedule
B. Positive reinforcement for performing activities of daily living
C. Stimulating environment
D. Use of validation techniques
C. Sundowning.
In clients with a cognitive impairment disorder, the phenomenon of increased confusion in the early
evening hours is called:
A. Aphasia.
B. Agnosia.
C. Sundowning.
D. Confabulation.
D. The client will follow an established schedule for activities of daily living.
Which of the following outcome criteria is appropriate for the client with dementia?
A. The client will return to an adequate level of self-functioning.
B. The client will learn new coping mechanisms to handle anxiety.
C. The client will seek out resources in the community for support.
D. The client will follow an established schedule for activities of daily living.
D. Validation techniques
During the home visit of a client with dementia, the nurse notes that an adult daughter persistently
corrects her father's misperceptions of reality, even when the father becomes upset and anxious.
Which intervention should the nurse teach the caregiver?
A. Anxiety-reducing measures
B. Positive reinforcement
C. Reality orientation techniques
D. Validation techniques
,NCM114-RLE-AlzheimersDisease-2.
A, C, and F
Mr. Lim who is diagnosed with moderate dementia has frequent catastrophic reactions during
shower time. Which of the following interventions should be implemented in the plan of care?
Select all that apply.
A. Assign consistent staff members to assist the client.
B. Accomplish the task quickly, with several staff members assisting.
C. Schedule the client's shower at the same time of day.
D. Sedate the client 30 minutes prior to showering.
E. Tell the client to remain calm while showering.
F. Use a calm, supportive, quiet manner when assisting the client.
1. Alzheimer disease is the most common form of which of these?
The correct answer is B. Dementia.
It is a collection of symptoms characterized by decreasing intellectual and social abilities.
2. How is Alzheimer disease diagnosed?
The correct answer is D. All of the above.
No single test identifies Alzheimer disease. Lab tests help rule out other disorders that may produce
similar symptoms. Neurological and mental-status tests reveal cognitive-function deficits.
3. Physiologically, what happens to the brain as Alzheimer disease progresses?
The correct answer is C. Many cells die.
Nerve cells change in certain parts of the brain, which causes brain cells to die. The loss of cells
impairs thinking and judgment.
4. Which of these is the strongest risk factor for developing the disease?
The correct answer is B. Age.
Although some studies have shown an association between certain modifiable lifestyle factors and a
reduced risk for Alzheimer disease, the National Institutes of Health says that age is the strongest
known risk factor where most people receive the diagnosis after age 60. An early onset familial form
can also occur, although it is rare.
5. Occasionally, other health conditions may mimic this disease. What are they?
The correct answer is D. All of the above.
Dementia can result from a variety of causes, but when Alzheimer is involved, dementia is
irreversible and progressive.
6. Signs of Alzheimer disease include which of these symptoms?
The correct answer is D. All of the above.
Alzheimer sufferers also can't learn new information and tend to repeat themselves.
7. Which age group has the highest rate of Alzheimer cases reported?
The correct answer is A. 85 and older.
8. Because no medicines cure this condition, emphasis is put on delaying the onset of severe
symptoms. Which of these strategies helps?
The correct answer is D. All of the above.
Help keep the person's body physically active and mind engaged as long as possible.
9. The average time from the onset of symptoms to death is how long?
The correct answer is B. 8 years.
Alzheimer patients may live as few as 3 years or as long as 20 years with the disease.
10. If you care for a relative with Alzheimer disease, which of these measures will help stabilize
the patient mentally?
The correct answer is C. Establish a regular routine.
, NCM114-RLE-AlzheimersDisease-2.
If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the
nurse would anticipate that the client has problems with:
A. body temperature control.
B. balance and equilibrium.
C. visual acuity.
D. thinking and reasoning
A
A female client admitted to an acute care facility after a car accident develops signs and symptoms
of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation
to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates
administering which drug endotracheally before suctioning?
A. phenytoin (Dilantin)
B. mannitol (Osmitrol)
C. lidocaine (Xylocaine)
D. furosemide (Lasix)
C
After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the
emergency department. He's unconscious and his pupils are nonreactive. Which intervention would
be the most dangerous for the client?
A. Give him a barbiturate.
B. Place him on mechanical ventilation.
C. Perform a lumbar puncture.
D. Elevate the head of his bed.
C
When obtaining the health history from a male client with retinal detachment, the nurse expects the
client to report:
A. light flashes and floaters in front of the eye.
B. a recent driving accident while changing lanes.
C. headaches, nausea, and redness of the eyes.
D. frequent episodes of double vision.
A
Which nursing diagnosis takes highest priority for a client with Parkinson's crisis?
a. Imbalanced nutrition: Less than body requirements
b. Ineffective airway clearance
c. Impaired urinary elimination
d. Risk for injury
B
To encourage adequate nutritional intake for a female client with Alzheimer's disease, the nurse
should:
a. stay with the client and encourage him to eat.
b. help the client fill out his menu.
c. give the client privacy during meals.
d. fill out the menu for the client.
A
The nurse is performing a mental status examination on a male client diagnosed with subdural
hematoma. This test assesses which of the following?
a. Cerebellar function
b. Intellectual function
c. Cerebral function
d. Sensory function
