A family member brought a senior to the clinic. The family member explained to the nurse that the patient suddenly from one day to the other, started with confusion, and agitation. The family states the patient used to be orientated and with very calm behavior. The nurse suspects that this patient is experiencing:

Delirium

Sundowning

Alzheimers

Dementia

Answer and Explanation

The Correct Answer is A

A. Delirium: Delirium is characterized by a sudden onset of confusion, agitation, and fluctuating levels of consciousness. It often develops over a short period, such as hours to days, and is typically associated with an underlying medical condition, medication, or infection. The patient's rapid change from being oriented and calm to confused and agitated suggests a sudden onset, which is indicative of delirium.
B. Sundowning: Sundowning refers to a pattern of increased confusion and agitation that occurs in the late afternoon or evening, primarily in individuals with dementia. While it involves fluctuations in mental status, it does not usually present with a sudden onset of symptoms as described in this case.
C. Alzheimer’s: Alzheimer’s disease is a form of chronic dementia characterized by gradual and progressive cognitive decline over months to years. The sudden onset of confusion and agitation does not align with the gradual progression typical of Alzheimer's disease.
D. Dementia: Dementia is a general term for a decline in cognitive ability that affects daily life, usually developing gradually over time. Unlike delirium, dementia does not present with a sudden change in behavior or mental status, making it less likely in this scenario where the change was abrupt.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A) Assess for Kernig and Brudzinski signs: Kernig and Brudzinski signs are used to test for meningeal irritation, often associated with conditions like meningitis. However, these tests should not be performed if there is a risk of spinal injury, as they could potentially exacerbate any existing cervical spine injury.
B) Ensure no injury to the cervical spine: Before performing tests that involve neck movements, such as those for meningeal irritation, it is crucial to ensure that there is no existing cervical spine injury. Performing such tests on a client with a cervical spine injury could lead to further harm. Therefore, checking for cervical spine stability and injury is the most important initial step.
C) Check for a Babinski reflex: The Babinski reflex is used to assess neurological function but is not specifically related to detecting meningeal irritation. It is not the immediate priority when evaluating for possible cervical spine injury.

D) Position the client prone: Positioning the client prone is not relevant for assessing meningeal irritation and may not be appropriate depending on the client’s condition. The focus should be on ensuring the client's safety and stability before performing specific physical tests.

A. Trochlear B. Optic C. Oculomotor D. Abducens E. Facial

Correct Answer is ["A","C","D"]

Explanation

A) Trochlear: The trochlear nerve (CN IV) is responsible for innervating the superior oblique muscle, which helps control the downward and inward movement of the eye.
B) Optic: The optic nerve (CN II) is primarily involved in vision and visual acuity, not in the movement of the eye. It transmits visual information from the retina to the brain.
C) Oculomotor: The oculomotor nerve (CN III) controls most of the extraocular muscles, including those responsible for eye movement (superior rectus, inferior rectus, medial rectus, and inferior oblique) and also controls pupil constriction.
D) Abducens: The abducens nerve (CN VI) controls the lateral rectus muscle, which is responsible for the outward movement of the eye.
E) Facial: The facial nerve (CN VII) controls the muscles of facial expression and is not involved in eye movements.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When preparing to test a client for meningeal irritation, which of the following would be most important for the nurse to do first?

Correct Answer is B

Explanation

Which cranial nerves are involved in eye movements? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

During an abdominal examination, the nurse palpates a bulging area in the Right Lower Quadrant of a female patient. The nurse suspects that this mass could be associated with which of the following organs? (Select all that apply.)

The nurse reads in the patient chart the doctor's day round note. The doctor writes AOX3, the nurse knows this means the patient is oriented to: Select all that apply.

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

Assessment of the client reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following?

A nurse is doing a community teaching about the consequences of uncontrolled hypertension. What health problems should the nurse describe? Select all that apply.

A nurse teaches a male client how to perform testicular self-examination when the client's history reveals that he does not do it. The nurse would instruct the client to perform the self-examination at which frequency?

A client who suffered a stroke 6 months ago and participating in a rehab program is able to actively move the both lower legs against gravity and some resistance. How should the nurse document this finding using the muscle strength grading scale?

The nurse asks the client to "place one hand behind the back and touch the shoulder blade" in the position shown. The patient explains he cannot perform the movement. What MOST likely is causing the patient decreased range of motion (ROM) in this joint?