Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale

Splitting is a defense mechanism where a person sees things in black-and-white, without the capacity to recognize nuances or integrate good and bad qualities together.

Choice B rationale

Suppression is a conscious decision to delay dealing with stressors or emotions until a later time, as the client does by focusing on their son’s wedding before addressing their health.

Choice C rationale

Reaction formation involves behaving in a way that's opposite to one's true feelings, which does not align with the client's expressed actions.

Choice D rationale

Projection is attributing one's own thoughts, feelings, or impulses to another person, not evident in the client's behavior.

A. Provide the client with a dark environment for sleeping. B. Repeat orientation asks until the client gives a correct response. C. Give the client a list of foods to choose from for dinner. D. Make a personal introduction to the client at each interaction.

Correct Answer is D

Explanation

Choice A rationale

Providing the client with a dark environment for sleeping can aid in better rest and sleep quality, which is particularly important for clients with dementia who may have disrupted sleep patterns. However, it's essential to ensure that the environment is safe to prevent any accidents due to poor visibility.

Choice B rationale

Repeating orientation tasks until the client gives a correct response can help reinforce their memory and cognitive function. This practice is known as reality orientation, which is a therapeutic technique used to improve awareness of time, place, and person in clients with dementia.

Choice C rationale

Giving the client a list of foods to choose from for dinner provides autonomy and encourages decision-making. It helps in maintaining cognitive function and personal preferences, which can positively impact their mental health and quality of life.

Choice D rationale

Making a personal introduction to the client at each interaction helps in establishing a connection and reducing confusion. Clients with dementia often have short-term memory loss, so frequent reintroduction can provide reassurance and familiarity, contributing to their sense of security. .

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

A nurse is caring for a client who has a new diagnosis of cancer.The client states, "I can't think about my health until after my son is married next week.”. The nurse should identify the client's statement as an indication of which of the following maladaptive defense mechanisms?

Correct Answer is B

Explanation

A nurse is assisting with the care of a client who has dementia.Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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 caring for a client who has an anxiety disorder.The client transforms their anxiety into physical manifestations.The nurse should recognize that the client is exhibiting which of the following manifestations?

A nurse is caring for a newly admitted client who has obsessive-compulsive disorder.Which of the following actions should the nurse take first?

A nurse is caring for a 65-year-old male client in the emergency department (ED). Exhibits For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.

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 in a substance use disorder clinic is explaining the alcohol recovery process to a client's family.Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?

A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide.Which of the following findings should the nurse identify as a risk factor for suicide?

A nurse is reinforcing teaching about a new prescription for haloperidol with a client who has schizophrenia.Which of the following statements by the client indicates an understanding of the teaching?