NURS COMPLEX ADULT HEALTH EXAM 1 QUESTIONS
WITH ANSWERS AND RATIONALE GRADED A+
SUCCESS GUARANTEED
A nurse is caring for a group of older adult clients. Which of the following
manifestations indicates 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. -Correct Answer= 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 hospitalization, 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 community health nurse is providing teaching to the family of a client who
has primary dementia. 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. -Correct 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.)
,NURS COMPLEX ADULT HEALTH EXAM 1 QUESTIONS
WITH ANSWERS AND RATIONALE GRADED A+
SUCCESS GUARANTEED
A nurse is caring for a client who has dementia. When performing a Mental
Status Examination (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 -Correct Answer= A, C, E.
(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 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 responses 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." -Correct
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, 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 disorders 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.
,NURS COMPLEX ADULT HEALTH EXAM 1 QUESTIONS
WITH ANSWERS AND RATIONALE GRADED A+
SUCCESS GUARANTEED
C. limit time for the client to perform activities.
D. talk the client through tasks one step at a time. -Correct Answer= D
, NURS COMPLEX ADULT HEALTH EXAM 1 QUESTIONS
WITH ANSWERS AND RATIONALE GRADED A+
SUCCESS GUARANTEED
(The nurse should plan to talk the client through tasks one step at a time to
minimize confusion and promote independence, which will decrease the
client's anxiety level.)
A nurse is caring for a client who is cognitively impaired. Which of the
following rooms will provide a therapeutic environment for this client?
A. A room adjacent to the nursing station
B. A room without a window
C. A room with dim lighting
D. A room containing personal belongings -Correct Answer= D
(A room that contains several of the clients personal belongings assists in
maintaining personal identity and provides a therapeutic environment)
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 -Correct Answer= C
(since the client was manifesting signs of confusion before coming to the
emergency department and currently seems unable to understand or
respond to speech, the nurse should determine that the client has confusion)
A nurse is performing a mental status examination (MSE) on a client who has
a new diagnosis of dementia. Which of the following components should the
nurse include? (Select all that apply.)
A. grooming
B. long-term memory
C. support systems
D. affect
E. presence of pain -Correct Answer= A, B, D
(Grooming is included in an MSE which consists of appearance, behavior,
speech, mood, disorders of the form of thought, perceptual disturbances,
cognition, and ideas of harming self or others. Long-term memory is included
WITH ANSWERS AND RATIONALE GRADED A+
SUCCESS GUARANTEED
A nurse is caring for a group of older adult clients. Which of the following
manifestations indicates 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. -Correct Answer= 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 hospitalization, 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 community health nurse is providing teaching to the family of a client who
has primary dementia. 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. -Correct 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.)
,NURS COMPLEX ADULT HEALTH EXAM 1 QUESTIONS
WITH ANSWERS AND RATIONALE GRADED A+
SUCCESS GUARANTEED
A nurse is caring for a client who has dementia. When performing a Mental
Status Examination (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 -Correct Answer= A, C, E.
(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 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 responses 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." -Correct
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, 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 disorders 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.
,NURS COMPLEX ADULT HEALTH EXAM 1 QUESTIONS
WITH ANSWERS AND RATIONALE GRADED A+
SUCCESS GUARANTEED
C. limit time for the client to perform activities.
D. talk the client through tasks one step at a time. -Correct Answer= D
, NURS COMPLEX ADULT HEALTH EXAM 1 QUESTIONS
WITH ANSWERS AND RATIONALE GRADED A+
SUCCESS GUARANTEED
(The nurse should plan to talk the client through tasks one step at a time to
minimize confusion and promote independence, which will decrease the
client's anxiety level.)
A nurse is caring for a client who is cognitively impaired. Which of the
following rooms will provide a therapeutic environment for this client?
A. A room adjacent to the nursing station
B. A room without a window
C. A room with dim lighting
D. A room containing personal belongings -Correct Answer= D
(A room that contains several of the clients personal belongings assists in
maintaining personal identity and provides a therapeutic environment)
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 -Correct Answer= C
(since the client was manifesting signs of confusion before coming to the
emergency department and currently seems unable to understand or
respond to speech, the nurse should determine that the client has confusion)
A nurse is performing a mental status examination (MSE) on a client who has
a new diagnosis of dementia. Which of the following components should the
nurse include? (Select all that apply.)
A. grooming
B. long-term memory
C. support systems
D. affect
E. presence of pain -Correct Answer= A, B, D
(Grooming is included in an MSE which consists of appearance, behavior,
speech, mood, disorders of the form of thought, perceptual disturbances,
cognition, and ideas of harming self or others. Long-term memory is included
