ST. TONIS COLLEGECollege Of Nursing

Bulanao, Tabuk City, Kalinga

Nursing Care Management 105 : Cognitive Disorders

Name : Section : Date :

IINSTRUCTIONS: Choose and encircle the best answer for the following items. No erasures, alterations, and unnecessary markings. Make your answer sheets as clean as possible.

1. On a 24-hour assessment, the nurse documents that a client diagnosed with Alzheimer’s disease presents with aphasia. Which client behavior supports this finding?A. The client is sad and has no ability to experience pleasure.B. The client is extremely emaciated and appears to be

wasting away.C. The client is having difficulty in forming words.D. The client is no longer able to speak.

2. A client newly diagnosed with Alzheimer’s disease was admitted 72 hours ago. The client states, “Last night I went on a wonderful dinner cruise.” Which type of communication is this client expressing, and what is the underlying reason for its use?A. The client is using confabulation to achieve secondary

gains.B. The client is using confabulation to protect the ego.C. The client is using perseveration to divert attention.D. The client is using perseveration to maintain self-esteem.

3. After dementia has been ruled out, a client is diagnosed with pseudodementia (depression). Which of the following client symptoms would support this diagnosis? Select all that apply.A. Slow progression of symptoms.B. Impaired attention and concentration.C. Diminished appetite.D. Symptoms diminish as the day progresses.E. Oriented to time and place with no wandering.

4. A client presents in the emergency department with an acute decrease in cognitive ability. The nurse’s assessment should include which of the following? Select all that apply.A. Family history and a mini-mental status examination.B. Laboratory tests and vital signs.C. Toxicology screen for illegal substances.D. Open-ended questions to obtain information.E. Familiarizing the client with the milieu.

5. The nurse suspects a client is experiencing delirium. Which specific assessment information would support this suspicion?A. A decreased level of consciousness with intermittent

hypervigilance.B. Slow onset of confusion and agitation.C. Onset is insidious and relentless.D. The symptoms last for 1 month or longer.

6. Studies have indicated that drastically reduced levels of acetylcholine are available in the brains of individuals diagnosed with Alzheimer’s disease. Which cognitive deficit is primarily associated with this reduction?A. Loss of memory.B. Loss of purposeful movement.C. Loss of sensory ability to recognize objects.D. Loss of language ability.

7. A client newly diagnosed with vascular dementia isolates self because of consistently poor role performance and increasing loss of independent functioning. Which nursing diagnosis reflects this client’s problem?A. Disturbed thought processes R / T decreased cerebral

circulation AEB disorientation.B. Risk for injury R /T poor role performance AEB decreased

functioning.C. Disturbed body image R /T loss of independent functioning

AEB tearful, sad affect.D. Low self-esteem R /T loss of independent functioning AEB

social isolation.8. An 80-year-old client admitted to the emergency department is

experiencing fever, dysuria, and urinary frequency. The client is combative and seeing things others do not see. Which nursing diagnosis reflects this client’s problem?A. Disturbed sensory perceptions R /T infection AEB visual

hallucinations.B. Risk for violence: self-directed R /T disorientation.

C. Self-care deficit R /T decreased perceived need AEB disheveled appearance.

D. Social isolation R /T decreased self-esteem.9. A client diagnosed with dementia has a nursing diagnosis of risk

for injury R /T extreme psychomotor agitation. Which would be an appropriate short-term outcome related to this problem?A. The client will remain free from injury during this shift.B. The client will ask the nurse for assistance when becoming

confused.C. The client will verbalize staff appreciation by day 3.D. The client will demonstrate ability to perform activities of

daily living on discharge.10. A nursing diagnosis of self-care deficit R/T memory loss AEB

inability to fulfill activities of daily living (ADLs) is assigned to a client diagnosed with Alzheimer’s disease. Which is an appropriate short-term outcome for this individual?A. The client participates in ADLs with assistance by

discharge.B. The client accomplishes ADLs without assistance after

discharge.C. By time of discharge, the client will exhibit feelings of self-

worth.D. The client will not experience physical injury.

11. A client who is delirious yells out to the nurse, “You are an idiot, get me your supervisor.” Which is the best nursing response in this situation?A. “You need to calm down and listen to what I’m saying.”B. “You’re very upset, I’ll call my supervisor.”C. “You’re going through a difficult time. I’ll stay with you.”D. “Why do you feel that my calling the supervisor will solve

anything?”12. A client diagnosed with dementia states, “I can’t believe it’s the

4th of July and it’s snowing outside.” Which is the nurse’s most appropriate response?A. “What makes you think it’s the 4th of July?”B. “How can it be July in winter?”C. “Today is March 12, 2007. Look, your lunch is ready.”D. “I’ll check to see if it’s time for your PRN haloperidol

(Haldol).”13. In writing a plan of care for a client diagnosed with dementia, the

nurse would consider which tertiary prevention intervention?A. Administer mini-mental status examination and document.B. Maintain routine to prevent further confusion and

disorientation.C. Obtain occupational therapy consultation to slow further

physical decline.D. Encourage socialization to prevent isolation and further

confusion.14. In writing a plan of care for a client diagnosed with dementia, the

nurse considers which of the following secondary prevention interventions? Select all that apply.A. Reinforce speech with nonverbal techniques by pointing to

and touching items.B. Keep surroundings simple by reducing clutter.C. Offer family ethics consultation or hospice assistance if

appropriate.D. Place large, visible clock and calendar in client’s room.E. Talk to family members about genetic predisposition

regarding dementia.15. In working with clients with late-stage Alzheimer’s dementia,

which is a priority intervention?A. Assist the client to consume fluids and food to prevent

electrolyte imbalance.B. Reorient the client to place and time frequently to reduce

confusion and fear.C. Encourage the client to participate in own activities of daily

living to promote selfesteem.

D. Assist with ambulation to avoid injury from falls.16. A client diagnosed with primary dementia has a nursing

diagnosis of altered thought process R /T disorientation and confusion. Which nursing intervention should be implemented first?A. Use tranquilizing medications and soft restraints.B. Continually orient client to reality and surroundings.C. Assess client’s level of disorientation and confusion.D. Remove potentially harmful objects from the client’s room.

17. A nursing student is studying delirium. Which of the following student statements indicates that learning has occurred? Select all that apply.A. “The symptoms of delirium develop over a short time.”B. “Delirium permanently affects the ability to learn new

information.”C. “Symptoms of delirium include the development of aphasia,

apraxia, and agnosia.”D. “Delirium is a disturbance of consciousness.”E. “Delirium is always secondary to another condition.”

18. A family member of a client experiencing dementia and being treated for normalpressure hydrocephalus asks the nurse, “Is my father’s dementia reversible?” Which nursing response indicates understanding of primary and secondary dementia?A. “Treatment sometimes can reverse secondary dementia.”B. “Unfortunately, primary dementia is not reversible.”C. “Unfortunately, secondary dementia is not reversible.”D. “Treatment sometimes can reverse primary dementia.”

19. On discharge, a client diagnosed with dementia is prescribed donepezil hydrochloride (Aricept). Which would the nurse include in a teaching plan for the client’s family?A. “Donepezil is a sedative/hypnotic used for short-term

treatment of insomnia.”B. “Donepezil is an Alzheimer’s treatment used for mild-to-

moderate dementia.”C. “Donepezil is an antipsychotic used for clients diagnosed

with dementia.”D. “Donepezil is an antianxiety agent used for clients

diagnosed with dementia.”20. An emaciated client diagnosed with delirium is experiencing

sleeplessness, auditory hallucinations, and vertigo. Meclizine (Antivert) has been prescribed. Which client response supports the effectiveness of this medication?A. The client no longer hears voices.B. The client sleeps through the night.C. The client maintains balance during ambulation.D. The client has an improved appetite.

-===== Good luck & God bless =====-

Prepared by:

Lucky P.Roaquin, RN, MANSTCI-CON Faculty