NR341 Complex Adult Health Exam 1
Textbook Questions with Rationales
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 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.
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 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.
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.) - -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
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.) - -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."
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.) -
-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.
D
✅✅
(A room that contains several of the clients personal belongings assists in maintaining
personal identity and provides a therapeutic environment) - -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
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) - -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
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
Textbook Questions with Rationales
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 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.
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 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.
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.) - -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
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.) - -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."
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.) -
-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.
D
✅✅
(A room that contains several of the clients personal belongings assists in maintaining
personal identity and provides a therapeutic environment) - -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
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) - -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
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
