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NR341 COMPLEX ADULT HEALTH EXAM 1 2024/2025 WITH 100% ACCURATE SOLUTIONS
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NR341 COMPLEX ADULT HEALTH EXAM 1 2024/2025 WITH 100% ACCURATE SOLUTIONS
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NR341 COMPLEX ADULT HEALTH EXAM 1 2024/2025 WITH100% ACCURATE SOLUTIONS
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. - precise 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. - precise 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 - precise 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.)
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." - precise
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.)
, 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. - precise 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.)
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 - precise answer ✔✔d
(a room that contains several of the clients personal belongings assists in
maintaining personal identity and provides a therapeutic environment)
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