ATI LPN
Psychiatric Nursing: Contemporary Practice 6th Edition
Chapter 38 : Neurocognitive Disorders Questions
Question 1 of 5
As part of a follow-up home visit to an 80-year-old client who has had surgery, the nurse discusses the client?s risk for delirium with his family members. Which of the following would the nurse include as placing the client at increased risk? Select all that apply.
Correct Answer: A,C,E
Rationale: Urinary tract infections (
A), acute stress (
C), and dehydration (E) are well-established risk factors for delirium in older adults, particularly post-surgery, as they disrupt physiological homeostasis. Hypertension (
B) is a chronic condition not directly linked to delirium unless acute. Bone fractures (
D) may contribute indirectly via pain or immobility but are less direct. Electrolyte balance (F) is not a risk factor; imbalance is.
Question 2 of 5
The nurse is caring for a client diagnosed with delirium who has been brought for treatment by his son. While taking the client?s history, which question would be most appropriate for the nurse to ask the client?s son?
Correct Answer: A
Rationale: Medications are a common cause of delirium, particularly in older adults, due to polypharmacy or side effects. Asking about recent medications (
A) is most appropriate to identify potential triggers. Falls or head injuries (
B) and strokes (
C) are relevant but less common causes. Major losses (
D) are more associated with depression than delirium.
Question 3 of 5
The nurse makes a home visit to a family caring for a client with Alzheimer?s disease. The client?s wife tells the nurse that she hasn?t been out of the house for more than 2 weeks because her sister has been unable to help her care for the client. Which nursing diagnosis would the nurse identify as the priority?
Correct Answer: C
Rationale: Caregiver Role Strain (
C) is the priority, as the wife?s social isolation and inability to leave the house directly indicate the burden of caregiving. Ineffective Family Coping (
A) is less specific, as it focuses on the family unit. Activity Intolerance (
B) pertains to the client, not the caregiver. Powerlessness (
D) is relevant but less immediate than role strain.
Question 4 of 5
A daughter brings her mother, who has Alzheimer?s disease, to the clinic. The client has been taking a cholinesterase inhibitor medication for 1 month. When assessing the client, the nurse would be alert for the possibility of which side effect?
Correct Answer: A
Rationale: Cholinesterase inhibitors, used for Alzheimer?s, commonly cause gastrointestinal distress (
A) due to increased acetylcholine activity affecting the digestive system. Headaches (
B), muscle tics (
C), and blurred vision (
D) are less common side effects of these medications.
Question 5 of 5
A son brings his mother to the clinic for an evaluation. The son?s mother has moderate Alzheimer?s disease without delirium. The nurse assesses the client for which of the following as the priority?
Correct Answer: D
Rationale: Catastrophic reactions (
D), emotional overreactions to minor stressors, are a priority in moderate Alzheimer?s due to their impact on safety and care. Hearing deficits (
A) are less urgent unless indicated. Mania (
B) is not typical in Alzheimer?s. Strange verbalizations (
C) may occur but are less critical than behavioral reactions.