NR341 Complex Adult Health Exam 1 Newest 2025
Textbook Questions and Correct Verified Answers with
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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. .....ANSWER..... B.
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(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.
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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.)
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
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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.)