PRN 1562 Mental Health practice 134 Questions and Verified Correct Answers Latest Update 2024 Version Guaranteed A+
- When administering a mental status examination to a patient with delirium, the nurse
should a.give the examination when the patient is well-rested.b.reorient the patient as needed during the examination.c.choose a place without distracting environmental stimuli.d.medicate the patient first to reduce anxiety. - CORRECT ANSWER: Correct Answer: C Rationale: Because overstimulation by environmental factors can distract the patient from the task of answering the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient's delirium.
Cognitive Level: Application Text Reference: pp. 1562, 1576-1577 Nursing Process: Implementation NCLEX: Physiological Integrity
A 56-year-old patient in the outpatient clinic is diagnosed with mild cognitive impairment (MCI).Which action will the nurse include in the plan of care?
- Suggest a move into an assisted living facility.
- Schedule the patient for more frequent appointments.
- Ask family members to supervise the patient's daily activities.
- Discuss the preventive use of acetylcholinesterase medications. - CORRECT
ANSWER:CORRECT ANSWER: B-Schedule the patient for more frequent appointments
A 62-year-old patient is brought to the clinic by a family member who is concerned about the patient's increasing sleep disturbances and inability to solve common problems. To obtain information about the patient's current mental status, which question should the nurse ask the patient?a."Where were you were born?" b."Do have any feelings of sadness?" c."What day of the week is it today?" d."How positive is your self-image?" - CORRECT ANSWER: Correct Answer: C Rationale: This question tests the patient's orientation to time, which is decreased in early Alzheimer's disease (AD) or dementia. Asking the patient about birthplace tests for 1 / 4
remote memory, which is intact in the early stages. Questions about the patient's emotions and self-image are helpful in assessing emotional status, but they are not as helpful in assessing mental state.
A 62-year-old woman is admitted to an assisted-living facility with symptoms of forgetfulness, irritability, difficulty following directions, and neglect of her personal hygiene. These would suggest which stage of AD?
- Late
- Early
- Moderate
D. Moderate to severe - CORRECT ANSWER: C. Moderate
A 68-year-old man is admitted to the emergency department with multiple blunt trauma following a one-vehicle car accident. He is restless; disoriented to person, place, and time; and agitated. He resists attempts at examination and calls out the name "Janice." Why should the nurse suspect delirium rather than dementia in this patient?
- The fact that he wouldn't have been allowed to drive if he had dementia
- His hyperactive behavior, which differentiates his condition from the hypoactive
- The report of emergency personnel that he was noncommunicative when they arrived
- The report of his family that although he has heart disease and is "very hard of
behavior of dementia
at the accident scene
hearing," this behavior is
unlike him - CORRECT ANSWER: d. Delirium is an acute problem that usually has a
rapid onset in response to a precipitating event, especially when the patient has underlying health problems, such as heart disease and sensory limitations. In the absence of prior cognitive impairment, a sudden onset of confusion, disorientation, and agitation is usually delirium. Delirium may manifest with both hypoactive and hyperactive symptoms.
A 69-year-old client is admitted and diagnosed with delirium. Later in the day, he tries to get out of the locked unit. He yells, "Unlock this door. I've got to go see my doctor. I just can't miss my monthly Friday appointment." Which of the following responses by the nurse is most appropriate?
- "Please come away from the door. I'll show you your room."
- "It's Tuesday and you are in the hospital. I'm Anne, a nurse."
- "The door is locked to keep you from getting lost."
- "I want you to come eat your lunch before you go the doctor." - CORRECT
ANSWER:2.
Loss of orientation, especially for time and place, is common in delirium. The nurse should orient the client by telling him the time, date, place, and who the client is with.Taking the client to his room and telling him why the door is locked does not address his disorientation. Telling the client to eat before going to the doctor reinforces his disorientation.
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A 71-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During assessment of the patient, the nurse would expect to find a.excessive nighttime sleepiness.b.variable ability to perform simple tasks.c.difficulty eating and swallowing.d.loss of recent and long-term memory. - CORRECT ANSWER: Correct Answer: D Rationale: Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient's ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia.
Cognitive Level: Application Text Reference: pp. 1562-1563 Nursing Process: Assessment NCLEX: Physiological Integrity
A 72-year-old female patient is brought to the clinic by the patient's spouse, who reports that she is unable to solve common problems around the house. To obtain information about the patient's current mental status, which question should the nurse ask the patient?
- "Are you sad?"
- "How is your self-image?"
- "Where were you were born?"
- "What did you eat for breakfast?" - CORRECT ANSWER:CORRECT ANSWER: D-
"What did you eat for breakfast?"
This question tests the patient's short-term memory, which is decreased in the mild stage of Alzheimer's disease or dementia
A 72-year-old patient hospitalized with pneumonia is disoriented and confused 2 days after admission. Which assessment information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia?a.The patient is disoriented to place and time but oriented to person.b.The patient has a history of increasing confusion over several years.c.The patient's speech is fragmented and incoherent.d.
The patient was oriented and alert when admitted. - CORRECT ANSWER: Correct
Answer: D
Rationale: The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is 3 / 4
consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia.
Cognitive Level: Application Text Reference: p. 1562 Nursing Process: Assessment NCLEX: Physiological Integrity
A client diagnosed with paranoid schizophrenia states, "My psychiatrist is out to get me.I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom?
- Magical thinking; administer an antipsychotic medication
- Persecutory delusions; orient the client to reality
- Command hallucinations; warn the psychiatrist
- Altered thought processes; call an emergency treatment team meeting - CORRECT
ANSWER:CORRECT ANSWER: C
The nurse should determine that the client is exhibiting command hallucinations. The nurse's legal responsibility is to warn the psychiatrist of the potential for harm. A client who is demonstrating a risk for violence could potentially become physically, emotionally, and/or sexually harmful to others or to self.
A client has a history of daily bourbon drinking for the past 6 months. He is brought to an emergency department by family who report that his last drink was 1 hour ago. It is now 12 midnight. When should a nurse expect this client to exhibit withdrawal symptoms?
- Between 3 a.m. and 11 a.m.
- Shortly after a 24-hour period
- At the beginning of the third day
- Withdrawal is individualized and cannot be predicted. - CORRECT
ANSWER:CORRECT ANSWER: A
The nurse should expect that this client will begin experiencing withdrawal symptoms from alcohol between 3 a.m. and 11 a.m. Symptoms of alcohol withdrawal usually occur within 4 to 12 hours of cessation or reduction in heavy and prolonged alcohol use.
A client has sought treatment for a specific phobia: fear of cats. The nurse in the anxiety disorders clinic has established the nursing diagnosis, Anxiety related to exposure to phobic object (cats). A realistic short-term goal for this client would be: within 10 days, client will
- avoid feared object whenever possible.
- face feared object unassisted.
- state that feared object no longer produces feelings of dread associated with anxiety.
- practice relaxation techniques and report less distress related to thoughts of the
feared object. - CORRECT ANSWER: 4. practice relaxation techniques and report less distress related to thoughts of the feared object.
Rationale: When the client is able to relax in the presence of thoughts, or the phobic object, the client will begin to experience a sense of control over the phobia
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