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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

Light therapy can be an effective treatment for certain conditions, like seasonal affective disorder, but it typically does not require informed consent unless it's experimental or has significant risks.

Choice B rationale

Experimental medications require informed consent due to the potential unknown effects and risks. Ensuring the client is fully informed about the experimental nature and possible side effects is crucial.

Choice C rationale

Participating in a group exercise program generally does not require informed consent. These activities are typically part of routine care and considered low risk.

Choice D rationale

Attending a cognitive behavioral therapy class usually does not require informed consent beyond the initial agreement to participate in therapy. These sessions are standard parts of mental health care.

A. Phenobarbital. B. Diazepam. C. Chlordiazepoxide. D. Buprenorphine.

Correct Answer is D

Explanation

Choice A rationale

Phenobarbital is not typically used for opioid use disorder; it is more commonly used for seizure disorders and as a sedative.

Choice B rationale

Diazepam is a benzodiazepine, used for anxiety and muscle spasms, but not for treating opioid use disorder.

Choice C rationale

Chlordiazepoxide is another benzodiazepine used for alcohol withdrawal, not opioid use disorder.

Choice D rationale

Buprenorphine is a partial opioid agonist used in medication-assisted treatment for opioid use disorder, helping to reduce cravings and withdrawal symptoms.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has bipolar disorder and whose admission was voluntary.For which of the following interventions should the nurse confirm that the client has given informed consent?

Correct Answer is B

Explanation

A nurse is caring for a client who has an opioid use disorder.The nurse should anticipate that the provider will prescribe which of the following medications for treatment?

Correct Answer is D

Explanation

A nurse is caring for multiple clients on a mental health unit.Which of the following clients should the nurse attend to first?

A nurse is caring for a client who is experiencing a situational crisis.Which of the following actions should the nurse take first?

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

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 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 client who is receiving acute care for the treatment of a substance use disorder.With which of the following actions is the nurse demonstrating the ethical principle of veracity?

A nurse is caring for a client who has dementia and is experiencing an increased number of falls.Which of the following actions should the nurse take?

A nurse is collecting data from a client who has antisocial personality disorder.Which of the following findings should the nurse expect?