Chapter 38: Neurocognitive Disorders - Nurselytic

Questions 20

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Psychiatric Nursing: Contemporary Practice 6th Edition

Chapter 38 : Neurocognitive Disorders Questions

Question 1 of 5

The nurse is assessing a client who has received a tentative diagnosis of delirium. The nurse is explaining to the family about the major cause of the client?s condition. Which statement by the nurse would be most appropriate?

Correct Answer: C

Rationale: Delirium is characterized by a rapid onset of altered consciousness and cognitive impairment, distinguishing it from dementia, which develops gradually. Option A is incorrect, as speech issues are not the primary diagnostic criterion. Option B describes dementia, not delirium. Option D assumes an infectious cause without evidence.

Question 2 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 3 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 4 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 5 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.

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