NR341 Complex Adult Health Exam 1 Textbook
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A nurse is caring for a client who has dementia due to
Alzheimer's disease and was admitted to a long-term care
facility following the death of her partner of 40 years. The
client states, " I want to go home; my husband is waiting
for me to cook dinner. "Which of the following responses
by the nurse is appropriate?
A. " this is where you live now."
B. " this is a safer place for you to live."
C. "Tell me what you like to cook for dinner."
D. "Your family said there is no one to care for you at
home." - Answer-C.
(Alzheimer's disease is a progressive cognitive disorder.
Dementia due to Alzheimer's disease means that the client
is experiencing the later stages of the illness with
moderately severe to severe cognitive decline. By asking
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the client to talk about what she likes to cook for dinner,
the nurse is demonstrating validation therapy by asking
the client to talk about the areas that concerned her. The
nurse could continue the conversation by discussing how
much the client misses her home and partner. Validation
therapy helps clients who have cognitive disorders discuss
their feelings about past events and people.)
A nurse on a long-term care unit is creating a plan of care
for a client who has Alzheimer's disease. Which of the
following interventions should the nurse include in the
plan?
A. rotate assignment of daily caregivers.
B. provide an activity schedule that changes from day to
day.
C. limit time for the client to perform activities.
D. talk the client through tasks one step at a time. -
Answer-D
(The nurse should plan to talk the client through tasks one
step at a time to minimize confusion and promote
independence, which will decrease the client's anxiety
level.)
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A nurse is caring for a client who is cognitively impaired.
Which of the following rooms will provide a therapeutic
environment for this client?
A. A room adjacent to the nursing station
B. A room without a window
C. A room with dim lighting
D. A room containing personal belongings - Answer-D
(A room that contains several of the clients personal
belongings assists in maintaining personal identity and
provides a therapeutic environment)
The family of an older adult client brings him to the
emergency department after finding him wandering
outside. During the initial assessment, the nurse notes that
the client flinches when she palpates his abdomen yet
response to questions only by nodding and smiling. Which
of the following factors should the nurse identify as a likely
explanation for the clients behavior?
A. he is hard of hearing
B. pain
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C. confusion
D. language barrier - Answer-C
(since the client was manifesting signs of confusion before
coming to the emergency department and currently seems
unable to understand or respond to speech, the nurse
should determine that the client has confusion)
A nurse is performing a mental status examination (MSE)
on a client who has a new diagnosis of dementia. Which of
the following components should the nurse include?
(Select all that apply.)
A. grooming
B. long-term memory
C. support systems
D. affect
E. presence of pain - Answer-A, B, D
(Grooming is included in an MSE which consists of
appearance, behavior, speech, mood, disorders of the