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.

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

Explanation

A. Weber test: The Weber test is used to assess hearing by placing a vibrating tuning fork on the center of the forehead. It helps evaluate lateralization of sound and can indicate whether hearing loss is conductive or sensorineural. This test is pertinent for assessing CN VIII, which is responsible for hearing.
B. Magazine: This option is not relevant to the assessment of CN VIII. A magazine is not used in evaluating hearing or vestibular function. The appropriate assessments for CN VIII focus on hearing and balance.
C. Rinne test: The Rinne test involves placing a vibrating tuning fork on the mastoid bone and then near the ear canal to compare air conduction (AC) and bone conduction (BC) of sound. This test helps differentiate between conductive and sensorineural hearing loss and is directly related to assessing CN VIII.
D. Whispered voice test: This test involves the nurse whispering numbers or words while occluding one ear and assessing the client's ability to hear and repeat them. It is a simple way to assess hearing ability and thus evaluates the function of CN VIII.

A. 20 represents the distance a normal eye can read and 40 represents the distance your eye read the chart. B. 20 represents the distance you are placed from the chart and 40 represents the distance a normal eye read the chart. C. 20 represents the distance you are placed from the chart and 40 represents the distance your eye read the chart. D. 40 represents the distance you are placed from the chart and 20 represents the distance normal eye read the chart.

Correct Answer is B

Explanation

A) 20 represents the distance a normal eye can read and 40 represents the distance your eye read the chart: This option incorrectly reverses the interpretation of the numbers. The correct interpretation is that the first number represents the distance at which the patient is reading the chart, and the second number represents the distance at which a person with normal vision would be able to read the same line.
B) 20 represents the distance you are placed from the chart and 40 represents the distance a normal eye read the chart: This is the correct interpretation of visual acuity. In the Snellen chart system, the first number (20) represents the distance (in feet) from which the patient is viewing the chart, while the second number (40) represents the distance at which a person with normal vision (20/20) would be able to read the same line of the chart.
C) 20 represents the distance you are placed from the chart and 40 represents the distance your eye read the chart: This option is incorrect because it does not accurately describe what the numbers mean. The second number represents the distance at which normal vision can read the line, not the distance the patient’s eye read the chart.
D) 40 represents the distance you are placed from the chart and 20 represents the distance normal eye read the chart: This option incorrectly assigns the numbers. The distance of 20 feet is standard for testing vision, and 40 feet is the benchmark for normal vision. The correct understanding is that 20 is the test distance, and 40 is the comparison distance for normal vision.

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Naxlex Comprehensive Predictor Exams

How would the nurse assess CN VIII Acoustic, vestibulocochlear: Select all that Apply

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

Explanation

A nurse is performing a complete physical examination on a patient. After examining the patient with the Snellen chart, the nurse documented distance vision in both eyes 20/40. The patient asks the nurse what 20/40 means:

Correct Answer is B

Explanation

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