NR 341 Complex Adult Health Exam 1 Questions with Rationales

NR 341 Complex Adult Health Exam 1 Questions with Rationales A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium? A. A client wants to know the current time while there is a clock on the wall. B. A client attempts to climb out of bed and repeatedly states she must get home. C. A client requests extra blankets when the thermostat in the room indicates 25.6 Degrees C (78 F). D. A client refuses to get out of bed and has no motivation to attend to daily hygiene. -Correct Answer= B. (Delirium is characterized by a change in cognition that occurs over a short period of time. It results from a secondary physiological condition (e.g., infection, surgery, prolonged hospitalization, hypoxia, fever, medications) and is a transient disorder. Although delirium can occur with any age, it is more common in older adults. It frequently progresses in the evening hours and is sometimes called "sundown syndrome." Delirium is characterized by alterations in memory, agitation, restlessness, illusions, or hallucinations. A client who becomes acutely confused and agitated may be showing manifestations of delirium.) 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. -Correct 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.) 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 -Correct 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.)