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A nurse is caring for a 76-year-old female client who experienced a fall.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to collect data about the client's progress.

Answer and Explanation

The Correct Answer is []

Condition: Alzheimer's disease.

2 actions:

Use symbols rather than written signs for directions,

Anticipate a prescription for donepezil.

2 parameters:

Presence of agnosia,

Ability to complete familiar tasks.

Rationale for correct condition: Alzheimer's disease explains the client's confusion, disorientation, and difficulty with familiar tasks. The client's inability to recall their home address and confusion with objects (call light and washcloth) aligns with cognitive decline. Alzheimer's disease often presents with memory loss and impaired judgment. The client's symptoms are progressive and not episodic. The overall presentation fits the profile of Alzheimer's disease.

Rationale for actions: Using symbols helps clients with Alzheimer's navigate and recognize their environment more easily. Symbols are easier to interpret than written signs. Donepezil can help manage symptoms by increasing acetylcholine levels. It supports cognitive function in Alzheimer's patients. Determining the date of the last eye examination is less relevant. Eye exams do not address cognitive decline directly. Duloxetine treats depression, not cognitive impairment. Monitoring agnosia tracks the client's ability to recognize objects. Completing familiar tasks assesses cognitive function. Night vision is less critical in cognitive assessment. Oxygen saturation is stable and not related to cognitive issues.

Rationale for parameters: Presence of agnosia helps identify progression of Alzheimer's. Monitoring familiar tasks assesses daily functioning and cognitive decline. Night vision is not directly related to cognitive assessment. Oxygen saturation is not affected by Alzheimer's. Cognitive tasks and object recognition are more relevant in this context.

Rationale for incorrect conditions: Expected aging process does not explain the severity of symptoms. Major depressive disorder presents differently with mood-related symptoms. Delirium is acute and reversible, not fitting the chronic, progressive nature of Alzheimer's disease.

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Correct Answer is B

Explanation

Choice A rationale

Making a unit calendar helps with orientation but doesn't specifically engage reminiscence therapy, which focuses on recalling past experiences.

Choice B rationale

Discussing childhood memories fosters reminiscence, aiding in cognitive stimulation and emotional connection among older adults.

Choice C rationale

Thought-stopping techniques are more suited for managing negative thoughts in disorders like anxiety or depression, not for reminiscence therapy.

Choice D rationale

Playing board games enhances cognition but doesn't specifically target reminiscence, which involves sharing and discussing past experiences.

A. Demonstrate a neutral demeanor. B. Use an overly friendly approach. C. Ask the client why he is suspicious of others.

Correct Answer is A

Explanation

Choice A rationale

Demonstrating a neutral demeanor helps build trust with a client who has a paranoid personality disorder. This approach is non-threatening and avoids triggering the client's suspicious tendencies.

Choice B rationale

Using an overly friendly approach can increase the client's suspicion and anxiety, making them feel manipulated or deceived.

Choice C rationale

Asking the client why they are suspicious can be perceived as confrontational and may cause the client to become defensive and less cooperative.

Choice D rationale

Being vague when answering the client's questions can increase their paranoia and mistrust, as it may seem like the nurse is hiding something.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with reminiscence therapy for a group of older adult clients.Which of the following strategies should the nurse implement?

Correct Answer is B

Explanation

A nurse is beginning a therapeutic relationship with a client who has paranoid personality disorder. Which of the following strategies should the nurse plan to use?

Correct Answer is A

Explanation

A nurse is contributing to the plan of care for a client who has acute delirium.Which of the following interventions should the nurse include in the plan of care?

A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior.Which of the following actions should the nurse take?

A client is becoming increasingly agitated, anxious, and tense.The nurse notes a clenched jaw and a change in the pitch of the client's voice.Which of the following interventions should the nurse implement first?

A nurse is contributing to the plan of care for a client who has a new prescription for lithium.Which of the following interventions should the nurse recommend?

A nurse is reviewing the medical record of a client who is to receive electroconvulsive therapy.The nurse should notify the provider for which of the following findings?

A nurse is speaking with the sibling of a client who refuses to see visitors.Which of the following actions should the nurse take?

A nurse is assisting with teaching a group of older adult clients about behavioral expectations.Which of the following actions should the nurse take to help eliminate barriers to learning?

A nurse is reinforcing teaching with the caregiver of a client who has Alzheimer's disease.The caregiver reports that the client awakens at night and wanders.Which of the following strategies should the nurse suggest?