COMPLEX ADULT HEALTH VIEW AHEAD EXAM QUESTIONS FULL SOLUTION GUIDE
Question:
A community health nurse is providing teaching to the family of a client who has primary dementia.
Which of the following manifestations should the nurse tell the family to expect? A. Decreased
auditory and visual acuity. B. Decreased display of emotion. C. Personality traits that are opposite of
original traits. D. Forgetfulness gradually progressing to disorientation.
Answer:
D. (Dementia usually appears first as forgetfulness. Other manifestations may be apparent only upon
neurologic examination or cognitive testing. Loss of functioning progresses slowly from impaired
language skills and difficulty with ordinary daily activities to severe memory loss and complete
disorientation with withdrawal from social interaction.)
Question:
A nurse is caring for a client who has dementia. When performing a Mental Status Examination
(MSE) the nurse should include which of the following data? (Select all that apply.) A. Ability to
perform calculations B. Level of consciousness C. Recall ability D. Long-term memory E. Level of
orientation
Answer:
A, C, E. (Evaluating the client's ability to perform calculations is an included component of an MSE.
Determining the client's level of consciousness is not a component of an MSE. Identifying the
client's ability to recall a list of objects or words is an included component of an MSE. Evaluating
long-term memory is not a component of an MSE. Determining the client's level of orientation is an
included component of an MSE.)
Question:
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 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.)
Question:
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.)
Question:
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)
Question:
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 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)
Question:
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 form of thought, perceptual disturbances, cognition, and ideas of harming self or
others. Long- term memory is included in an MSE which consists of appearance, behavior, speech,
and mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of
harming self or others. Support systems are not included in an MSE which consists of appearance,
behavior, speech, mood, disorders of the form of thought, perceptual disturbances, cognition, and
ideas of harming self or others. Affect is included in an MSE which consists of appearance,
behavior, speech, and mood, disorders of the form of thought, perceptual disturbances, cognition,
and ideas of harming self or others. The presence of pain is not included in an MSE which consists
of appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances,
cognition, and ideas of harming self or others.)
Question:
A nurse is caring for a client who has late stage Alzheimer's disease and is hospitalized for treatment
of pneumonia. During the night shift, the client is found climbing into the bed of another client who
becomes upset and frightened. Which of the following actions should the nurse take? A. assist the
client to the correct room. B. place the client in restraints. C. re-orient the client to time and place.
D. move the client to a room at the end of the hall.
Answer:
A (assisting the client to the correct room protects both clients. It helps re-orient the client who is
unable to find her own room, and it prevents the other client from an invasion of her personal space.)
Question:
Question:
A community health nurse is providing teaching to the family of a client who has primary dementia.
Which of the following manifestations should the nurse tell the family to expect? A. Decreased
auditory and visual acuity. B. Decreased display of emotion. C. Personality traits that are opposite of
original traits. D. Forgetfulness gradually progressing to disorientation.
Answer:
D. (Dementia usually appears first as forgetfulness. Other manifestations may be apparent only upon
neurologic examination or cognitive testing. Loss of functioning progresses slowly from impaired
language skills and difficulty with ordinary daily activities to severe memory loss and complete
disorientation with withdrawal from social interaction.)
Question:
A nurse is caring for a client who has dementia. When performing a Mental Status Examination
(MSE) the nurse should include which of the following data? (Select all that apply.) A. Ability to
perform calculations B. Level of consciousness C. Recall ability D. Long-term memory E. Level of
orientation
Answer:
A, C, E. (Evaluating the client's ability to perform calculations is an included component of an MSE.
Determining the client's level of consciousness is not a component of an MSE. Identifying the
client's ability to recall a list of objects or words is an included component of an MSE. Evaluating
long-term memory is not a component of an MSE. Determining the client's level of orientation is an
included component of an MSE.)
Question:
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 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.)
Question:
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.)
Question:
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)
Question:
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 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)
Question:
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 form of thought, perceptual disturbances, cognition, and ideas of harming self or
others. Long- term memory is included in an MSE which consists of appearance, behavior, speech,
and mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of
harming self or others. Support systems are not included in an MSE which consists of appearance,
behavior, speech, mood, disorders of the form of thought, perceptual disturbances, cognition, and
ideas of harming self or others. Affect is included in an MSE which consists of appearance,
behavior, speech, and mood, disorders of the form of thought, perceptual disturbances, cognition,
and ideas of harming self or others. The presence of pain is not included in an MSE which consists
of appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances,
cognition, and ideas of harming self or others.)
Question:
A nurse is caring for a client who has late stage Alzheimer's disease and is hospitalized for treatment
of pneumonia. During the night shift, the client is found climbing into the bed of another client who
becomes upset and frightened. Which of the following actions should the nurse take? A. assist the
client to the correct room. B. place the client in restraints. C. re-orient the client to time and place.
D. move the client to a room at the end of the hall.
Answer:
A (assisting the client to the correct room protects both clients. It helps re-orient the client who is
unable to find her own room, and it prevents the other client from an invasion of her personal space.)
Question:
