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An elderly woman's husband died.

When her brother arrives for the funeral, he notices her short-term memory problems and
occasional disorientation. A few weeks later, she calls him to say that her husband just died. She says, "I didn't know he was so
sick. Why did he die now?" She also complains of not sleeping, urinary frequency and burning, and seeing rats in the kitchen. A
home care nurse is sent to evaluate her situation and finds the woman reclusive and passive, but pleasant. The nurse calls the
woman's primary care physician to discuss the client's situation and background, and give his assessment and recommendations.
The nurse concludes that the woman:
1. Is experiencing the onset of Alzheimer's disease.
2. Is having trouble adjusting to living alone without her husband.
3. Is having delayed grieving related to her Alzheimer's disease.
4. Is experiencing delirium and a urinary tract infection.
4.
Delirium is commonly due to a medical condition such as a UTI in the elderly. Delirium often involves memory problems,
disorientation, and hallucinations. It develops rather quickly. There is not enough data to suggest Alzheimer's disease especially
given the quick onset of symptoms. Delayed grieving and adjusting to being alone are unlikely to cause hallucinations.

In or the discharge of a client with a cognitive disorder, it is important to assess the client's caregiver support system. Which
aspects are the most crucial to assess? Select all that apply.
1. Availability of resources for caregiver support.
2. Ability to provide the level of care and supervision needed by the client.
3. Willingness to transport the client to medical and psychiatric services.
4. Interest in engaging the cognitively disordered family member in reminiscence and games.
5. Willingness to install door alarms and make other safety changes.
6. Understanding the client's abilities and limitations.
1, 2, 3, 5, 6.
It is important for a caregiver to have support for herself as well as be able to provide adequate safety, supervision, and medical
care to the client. The caregiver must also have realistic expectations of the client, given his abilities and limitations. Reminiscing
and engaging the client in games is desirable but not crucial to care.

The son of an elderly client who has cognitive impairments approaches the nurse and says, "I'm so upset. The physician says I
have 4 days to decide on where my dad is going to live." The nurse responds to the son's concerns, gives him a list of types of
living arrangements, and discusses the needs, abilities, and limitations of the client. The nurse should intervene further if the son
makes which comment?
1. "Boy, I have a lot to think about before I see the social worker tomorrow."
2. "I think I can handle most of Dad's needs with the help of some home health care."
3. "I'm so afraid of making the wrong decision, but I can move him later if I need to."
4. "I want the social worker to make this decision so Dad won't blame me."
4.
Expecting the social worker to make the decision indicates that the son is avoiding participating in decisions about his father. The
other responses convey that the son understands the importance of a careful decision, the availability of resources, and the ability
to make new plans if needed.

Transfer data for a client brought by ambulance to the hospital's psychiatric unit from a nursing home indicate that the client has
become increasingly confused and disoriented. The client's behavior is found to be the result of cerebral arteriosclerosis. Which
of the following behaviors of the nursing staff should positively influence the client's behavior? Select all that apply.
1. Limiting the client's choices.
2. Accepting the client as he is.
3. Allowing the client to do as he wishes.
4. Acting nonchalantly.
5. Explaining to the client what he needs to do step-by-step.
1, 2, 5.
Confused clients need fewer choices, acceptance as a person, and step-by-step directions. Allowing the client to do as he wishes can
lead to substandard care and the risk of harm. Acting nonchalantly conveys a lack of caring.

The nurse observes a client in a group who is reminiscing about his past. Which effect should the nurse expect reminiscing to
have on the client's functioning in the hospital?
1. Increase the client's confusion and disorientation.
2. Cause the client to become sad.
3. Decrease the client's feelings of isolation and loneliness.
4. Keep the client from participating in therapeutic activities.
3.
Reminiscing can help reduce depression in an elderly client and lessens feelings of isolation and loneliness. Reminiscing
encourages a focus on positive memories and accomplishments as well as shared memories with other clients. An increase in
confusion and disorientation is most likely the result of other cognitive and situational factors, such as loss of short-term memory,
not reminiscing. The client will not likely become sad because reminiscing helps the client connect with positive memories.
Keeping the client from participating in therapeutic activities is less likely with reminiscing.

A 69-year-old client is admitted and diagnosed with delirium. Later in the day, he tries to get out of the locked unit. He yells,
"Unlock this door. I've got to go see my doctor. I just can't miss my monthly Friday appointment." Which of the following
responses by the nurse is most appropriate?
1. "Please come away from the door. I'll show you your room."
2. "It's Tuesday and you are in the hospital. I'm Anne, a nurse."
3. "The door is locked to keep you from getting lost."
4. "I want you to come eat your lunch before you go the doctor."
2.
Loss of orientation, especially for time and place, is common in delirium. The nurse should orient the client by telling him the
time, date, place, and who the client is with. Taking the client to his room and telling him why the door is locked does not address
his disorientation. Telling the client to eat before going to the doctor reinforces his disorientation.
An 83-year-old woman is admitted to the unit after being examined in the emergency department (ED) and diagnosed with
delirium. After the admission interviews with the client and her grandson, the nurse explains that there will be more laboratory
tests and X-rays done that day. The grandson says, "She has already been stuck several times and had a brain scan or something.
Just give her some medicine and let her rest." The nurse should tell the grandson which of the following? Select all that apply.
1. "I agree she needs to rest, but there is no one specific medicine for your grandmother's condition."
2. "The doctor will look at the results of those tests in the ED and decide what other tests are needed."
3. "Delirium commonly results from underlying medical causes that we need to identify and correct."
4. "Tell me about your grandmother's behaviors and maybe I could figure out what medicine she needs."
5. "I'll ask the doctor to postpone more tests until tomorrow."
1, 2, 3.
The client does need rest and it is true that there is no specific medicine for delirium, but it is crucial to identify and treat the
underlying causes of delirium. Other tests will be based on the results of already completed tests. Although some medications may
be prescribed to help the client with her behaviors, this is not the primary basis for medication orders. Because the underlying
medical causes of delirium could be fatal, treatment must be initiated as soon as possible. It is not the nurse's role to determine
medications for this client. Postponing tests until the next day is inappropriate.

The nurse is attempting to draw blood from a woman with a diagnosis of delirium who was admitted last evening. The client yells
out, "Stop; leave me alone. What are you trying to do to me? What's happening to me?" Which response by the nurse is most
appropriate?
1. "The tests of your blood will help us figure out what is happening to you."
2. "Please hold still so I don't have to stick you a second time."
3. "After I get your blood, I'll get some medicine to help you calm down."
4. "I'll tell you everything after I get your blood tests to the laboratory."
1.
Explaining why blood is being taken responds to the client's concerns or fears about what is happening to her. Threatening more
pain or promising to explain later ignores or postpones meeting the client's need for information. The client's statements do not
reflect loss of self control requiring medication intervention.

A 90-year-old client diagnosed with major depression is suddenly experiencing sleep disturbances, inability to focus, poor recent
memory, altered perceptions, and disorientation to time and place. Lab results indicate the client has a urinary tract infection
and dehydration. After explaining the situation and giving the background and assessment data, the nurse should make which of
the following recommendations to the client's physician?
1. An order to place the client in restraints.
2. A reevaluation of the client's mental status.
3. The transfer of the client to a medical unit.
4. A transfer of the client to a nursing home.
4.
The client is showing symptoms of delirium, a common outcome of UTI in older adults. The nurse can request a transfer to a
medical unit for acute medical intervention. The client's symptoms are not just due to a worsening of the depression. There are not
indications that the client needs restraints or a transfer to a nursing home at this point.

When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate?
1. Cancer of any kind.
2. Impaired hearing.
3. Prescription drug intoxication.
4. Heart failure.
3.
Polypharmacy is much more common in the elderly. Drug interactions increase the incidence of intoxication from prescribed
medications, especially with combinations of analgesics, digoxin, diuretics, and anticholinergics. With drug intoxication, the onset
of the delirium typically is quick. Although cancer, impaired hearing, and heart failure could lead to delirium in the elderly, the
onset would be more gradual.

In addition to developing over a period of hours or days, the nurse should assess delirium as distinguishable by which of the
following characteristics?
1. Disturbances in cognition and consciousness that fluctuate during the day.
2. The failure to identify objects despite intact sensory functions.
3. Significant impairment in social or occupational functioning over time.
4. Memory impairment to the degree of being called amnesia.
1.
Fluctuating symptoms are characteristic of delirium. The failure to identify objects despite intact sensory functions, significant
impairment in social or occupational functioning over time, and memory impairment to the degree

Which of the following is essential when caring for a client who is experiencing delirium?
1. Controlling behavioral symptoms with low-dose psychotropics.
2. Identifying the underlying causative condition or illness. 3. Manipulating the environment to increase orientation.
4. Decreasing or discontinuing all previously prescribed medications.
2.
The most critical aspect when caring for the client with delirium is to institute measures to correct the underlying causative
condition or illness. Controlling behavioral symptoms with low-dose psychotropics, manipulating the environment, and
decreasing or discontinuing all medications may be dangerous to the client's health.

Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium?
1. Explain the experience of having delirium.
2. Resume a normal sleep-wake cycle.
3. Regain orientation to time and place.
4. Establish normal bowel and bladder function.
3.
In approximately 2 to 3 days, the client should be able to regain orientation and thus become oriented to time and place. Being
able to explain the experience of having delirium is something that the client is expected to achieve later in the course of the
illness, but ultimately before discharge. Resuming a normal sleep-wake cycle and establishing normal bowel and bladder function
probably will take longer, depending on how long it takes to resolve the underlying condition.

Which of the following should the nurse expect to include as a priority in the plan of care for a client with delirium based on the
nurse's understanding about the disturbances in orientation associated with this disorder? 1. Identifying self and making sure
that the nurse has the client's attention.
2. Eliminating the client's napping in the daytime as much as possible.
3. Engaging the client in reminiscing with relatives or visitors.
4. Avoiding arguing with a suspicious client about his perceptions of reality.
1.
Identifying oneself and making sure that the nurse has the client's attention addresses the difficulties with focusing, orientation,
and maintaining attention. Eliminating daytime napping is unrealistic until the cause of the delirium is determined and the client's
ability to focus and maintain attention improves. Engaging the client in reminiscing and avoiding arguing are also unrealistic at
this time.

A client has been in the critical care unit for 3 days following a severe myocardial infarction. Although he is medically stable, he
has begun to have fluctuating episodes of consciousness, illogical thinking, and anxiety. He is picking at the air to "catch these
baby angels flying around my head." While waiting for medical and psychiatric consults, the nurse must intervene with the
client's needs. Which of the following needs have the highest priority? Select all that apply.
1. Decreasing as much "foreign" stimuli as possible.
2. Avoiding challenging the client's perceptions about "baby angels."
3. Orienting the client about his medical condition.
4. Gently presenting reality as needed.
5. Calling the client's family to report his onset of dementia.
1, 2, 4.
The abnormal stimuli of the critical care unit can aggravate the symptoms of delirium. Arguing with hallucinations is
inappropriate. When a client has illogical thinking, gently presenting reality is appropriate. Dementia is not the likely cause of the
client's symptoms. The client is experiencing delirium, not dementia.

A nurse on the Geropsychiatric unit receives a call from the son of a recently discharged client. He reports that his father just got
a prescription for memantine (Namenda) to take "on top of his donepezil (Aricept)." The son then asks, "Why does he have to
take extra medicines?" The nurse should tell the son:
1. "Maybe the Aricept alone isn't improving his dementia fast enough or well enough."
2. "Namenda and Aricept are commonly used together to slow the progression of dementia."
3. "Namenda is more effective than Aricept. Your father will be tapered off the Aricept."
4. "Aricept has a short half-life and Namenda has a long half-life. They work well together."
2.
The two medicines are commonly given together. Neither medicine will improve dementia, but may slow the progression. Neither
medicine is more effective than the other; they act differently in the brain. Both medicines have a half-life of 60 or more hours.

A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while
walking in the halls, the nurse should do which of the following?
1. Administer PRN haloperidol (Haldol) to decrease the need to walk.
2. Assess the client's gait for steadiness.
3. Restrain the client in a geriatric chair.
4. Administer PRN lorazepam (Ativan) to provide sedation.
2.
Elderly clients have increased risk for falls due to balance problems, medication use, and decreased eyesight. Haldol may cause
extrapyramidal side effects (EPSE) which increase the risk for falls. The client is not agitated, so restraints are not indicated.
Ativan may increase fall risk and cause paradoxical excitement.

A client with dementia who prefers to stay in his room has been brought to the dayroom. After 10 minutes, the client becomes
agitated and retreats to his room again. The nurse decides to assess the conditions in the dayroom. Which is the most likely
occurrence that is disturbing to this client?
1. There is only one other client in the dayroom; the rest are in a group session in another room.
2. There are three staff members and one physician in the nurse's station working on charting.
3. A relaxation tape is playing in one corner of the room, and a television airing a special on crime is playing in the opposite
corner.
4. A housekeeping staff member is washing off the countertops in the kitchen, which is on the far side of the dayroom.
3.
The tape and television are competing, even conflicting, stimuli. Crime events portrayed on television could be misperceived as a
real threat to the client. A low number of clients and the presence of a few staff members quietly working are less intense stimuli
for the client and not likely to be disturbing.

Nursing staff are trying to provide for the safety of an elderly female client with moderate dementia. She is wandering at night
and has trouble keeping her balance. She has fallen twice but has had no resulting injuries. The nurse should:
1. Move the client to a room near the nurse's station and install a bed alarm.
2. Have the client sleep in a reclining chair across from the nurse's station.
3. Help the client to bed and raise all four bedrails.
4. Ask a family member to stay with the client at night.
1.
Using a bed alarm enables the staff to respond immediately if the client tries to get out of bed. Sleeping in a chair at the nurse's
station interferes with the client's restful sleep and privacy. Using all four bedrails is considered a restraint and unsafe practice. It
is not appropriate to expect a family member to stay all night with the client.

During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with
her mother. She says, "She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore." Which
suggestions should the nurse make to the daughter? Select all that apply.
1. Ask the client's physician for a strong sleep medicine. 2. Establish a set routine for rising, hygiene, meals, short rest periods,
and bedtime.
3. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day.
4. Promote relaxation before bedtime with a warm bath or relaxing music.
5. Have the daughter encourage the use of caffeinated beverages during the day to keep her mother awake.
2, 3, 4.
A set routine and brief exercises help decrease daytime sleeping. Decreasing caffeine and fluids and promoting relaxation at
bedtime promote nighttime sleeping. A strong sleep medicine for an elderly client is contraindicated due to changes in
metabolism, increased adverse effects, and the risk of falls. Using caffeinated beverages may stimulate metabolism but can also
have long-lasting adverse effects and may prevent sleep at bedtime.

A client is experiencing agnosia as a result of vascular dementia. She is staring at dinner and utensils without trying to eat.
Which intervention should the nurse attempt first?
1. Pick up the fork and feed the client slowly.
2. Say, "It's time for you to start eating your dinner."
3. Hand the fork to the client and say, "Use this fork to eat your green beans."
4. Save the client's dinner until her family comes in to feed her.
3.
Agnosia is the lack of recognition of objects and their purpose. The nurse should inform the client about the fork and what to do
with it. Feeding the client does not address the agnosia or give the client specific directions. It should only be attempted if
identifying the fork and explaining what to do with it is ineffective. Waiting for the family to care for the client is not appropriate
unless identifying the fork and explaining or feeding the client are not successful.

A client with early dementia exhibits disturbances in her mental awareness and orientation to reality. The nurse should expect to
assess a loss of ability in which of the following other areas?
1. Speech.
2. Judgment.
3. Endurance.
4. Balance.
2.
Clients with chronic cognitive disorders experience defects in memory orientation and intellectual functions, such as judgment
and discrimination. Loss of other abilities, such as speech, endurance, and balance, is less typical.

The client with dementia states to the nurse, "I know you. You're Margaret, the girl who lives down the street from me." Which of
the following responses by the nurse is most therapeutic?
1. "Mrs. Jones, I'm Rachel, a nurse here at the hospital." 2. "Now Mrs. Jones, you know who I am."
3. "Mrs. Jones, I told you already, I'm Rachel and I don't live down the street."
4. "I think you forgot that I'm Rachel, Mrs. Jones."
1.
Because of the client's short-term memory impairment, the nurse gently corrects the client by stating her name and who she is.
This approach decreases anxiety, embarrassment, and shame and maintains the client's self-esteem. Telling the client that she
knows who the nurse is or that she forgot can elicit feelings of embarrassment and shame. Saying, "I told you already" sounds
condescending, as if blaming the client for not remembering.

While assessing a client diagnosed with dementia, the nurse notes that her husband is concerned about what he should do when
she uses vulgar language with him. The nurse should:
1. Tell her that she is very rude.
2. Ignore the vulgarity and distract her.
3. Tell her to stop swearing immediately.
4. Say nothing and leave the room.
2.
Vulgar language is common in clients with dementia when they are having trouble communicating about a topic. Ignoring the
vulgarity and distracting her is appropriate. Telling the client she is rude or to stop swearing will have no lasting effect and may
cause agitation. Just leaving the room is abandonment that the client will not understand.

The term motor apraxia relates to a decline in motor patterns essential for complex motor tasks. However, the client with severe
dementia may be able to perform which of the following actions?
1. Balance a checkbook accurately.
2. Brush the teeth when handed a toothbrush.
3. Use confabulation when telling a story.
4. Find misplaced car keys.
2.
Highly conditioned motor skills, such as brushing the teeth, may be retained by the client who has dementia and motor apraxia.
Balancing a checkbook involves calculations, a complex skill that is lost with severe dementia Confabulation is fabrication of
details to fill a memory gap. This is more common when the client is aware of a memory problem, not when dementia is severe.
Finding keys is a memory factor, not a motor function.

When communicating with the client who is experiencing dementia and exhibiting decreased attention and increased confusion,
which of the following interventions should the nurse employ as the first step?
1. Using gentle touch to convey empathy.
2. Rephrasing questions the client doesn't understand.
3. Eliminating distracting stimuli such as turning off the television.
4. Asking the client to go for a walk while talking.
3.
Competing and excessive stimuli lead to sensory overload and confusion. Therefore, the nurse should first eliminate any
distracting stimuli. After this is accomplished, then using touch and rephrasing questions are appropriate. Going for a walk while
talking has little benefit on attention and confusion.

While educating the daughter of a client with dementia about the illness, the daughter complains to the nurse that her mother
distorts things. The nurse understands that the daughter needs further teaching about dementia when she makes which
statement?
1. "I tell her reality, such as, 'That noise is the wind in the trees.'"
2. "I understand the misperceptions are part of the disease."
3. "I turn off the radio when we're in another room."
4. "I tell her she is wrong and then I tell her what's right."
4.
Telling the client that she is wrong and then telling her what is right is argumentative and challenging. Arguing with or challenging
distortions is least effective because it increases defensiveness. Telling the client about reality indicates awareness of the issues and
is appropriate. Acknowledging that misperceptions are part of the disease indicates an understanding of the disease and an
awareness of the issues. Turning off the radio helps to limit environmental stimuli and indicates an awareness of the issues.

The client in the early stage of Alzheimer's disease and his adult son attend an appointment at the community mental health
center. While conversing with the nurse, the son states, "I'm tired of hearing about how things were 30 years ago. Why does Dad
always talk about the past?" The nurse should tell the son:
1. "Your dad lost his short-term memory, but he still has his long-term memory."
2. "You need to be more accepting of your dad's behavior."
3. "I want you to understand your dad's level of anxiety."
4. "Telling your dad that you are tired of hearing about the past will help him stop."
1.
The son's statements regarding his father's recalling past events is typical for family members of clients in the early stage of
Alzheimer's disease, when recent memory is impaired. Telling the son to be more accepting is critical and not an attempt to
educate. Understanding the client's level of anxiety is unrelated to the memory loss of Alzheimer's disease. The client cannot stop
reminiscing at will.

The nurse discusses the possibility of a client's attending day treatment for clients with early Alzheimer's disease. Which of the
following is the best rationale for encouraging day treatment?
1. The client would have more structure to his day.
2. Staff are excellent in the treatment they offer clients.
3. The client would benefit from increased social interaction.
4. The family would have more time to engage in their daily activities.
3.
The best rationale for day treatment for the client with Alzheimer's disease is the enhancement of social interactions. More daily
structure, excellent staff, and allowing caregivers more time for themselves are all positive aspects, but they are less focused on the
client's needs.

When developing the plan of care for a client with Alzheimer's disease who is experiencing moderate impairment, which of the
following types of care should the nurse expect to include?
1. Prompting and guiding activities of daily living.
2. Managing a medication schedule.
3. Constant supervision and total care.
4. Supervision of risky activities such as shaving.
1.
Considerable assistance is associated with moderate impairment when the client cannot make decisions but can follow directions.
Managing medications is needed even in mild impairment. Constant care is needed in the terminal phase, when the client cannot
follow directions. Supervision of shaving is appropriate with mild impairment that is, when the client still has motor function but
lacks judgment about safety issues.

The family of a client, diagnosed with Alzheimer's disease, wants to keep the client at home. They say that they have the most
difficulty in managing his wandering. The nurse should instruct the family to do which of the following? (Select all that apply).
1. Ask the physician for a sleeping medication.
2. Install motion and sound detectors.
3. Have a relative sit with the client all night.
4. Have the client wear a Medical Alert bracelet.
5. Install door alarms and high door locks.
2, 4, 5.
Motion and sound detectors, a Medical Alert bracelet, and door alarms are all appropriate interventions for wandering. Sleep
medications do not prevent wandering before and after the client is asleep and may have negative effects. Having a relative sit with
the client is usually an unrealistic burden.

Which of the following is a priority to include in the plan of care for a client with Alzheimer's disease who is experiencing
difficulty processing and completing complex tasks?
1. Repeating the directions until the client follows them.
2. Asking the client to do one step of the task at a time.
3. Demonstrating for the client how to do the task.
4. Maintaining routine and structure for the client.
2.
Because the client is experiencing difficulty processing and completing complex tasks, the priority is to provide the client with only
one step at a time, thereby breaking the task up into simple steps, ones that the client can process. Repeating the directions until
the client follows them or demonstrating how to do the task is still too overwhelming to the client because of the multiple steps
involved. Although maintaining structure and routine is important, it is unrelated to task completion.
The client with Alzheimer's disease may have delusions about being harmed by staff and others. When the client expresses fear
of being killed by staff, which of the following responses is most appropriate?
1. "What makes you think we want to kill you?"
2. "We like you too much to want to kill you."
3. "You are in the hospital. We are nurses trying to help you."
4. "Oh, don't be so silly. No one wants to kill you here."
3.
The nurse needs to present reality without arguing with the delusions. Therefore, stating that the client is in the hospital and the
nurses are trying to help is most appropriate. The client doesn't recognize the delusion or why it exists. Telling the client that the
staff likes him too much to want to kill him is inappropriate because the client believes the delusions and doesn't know that they
are false beliefs. It also restates the word, kill, which may reinforce the client's delusions. Telling the client not to be silly is
condescending and disparaging and therefore inappropriate.

When helping the families of clients with Alzheimer's disease cope with vulgar or sexual behaviors, which of the following
suggestions is most helpful?
1. Ignore the behaviors, but try to identify the underlying need for the behaviors.
2. Give feedback on the inappropriateness of the behaviors.
3. Employ anger management strategies.
4. Administer the prescribed risperidone (Risperdal).
1.
The vulgar or sexual behaviors are commonly expressions of anger or more sensual needs that can be addressed directly.
Therefore, the families should be encouraged to ignore the behaviors but attempt to identify their purpose. Then the purpose can
be addressed, possibly leading to a decrease in the behaviors. Because of impaired cognitive function, the client is not likely to be
able to process the inappropriateness of the behaviors if given feedback. Likewise, anger management strategies would be
ineffective because the client would probably be unable to process the inappropriateness of the behaviors. Risperidone (Risperdal)
may decrease agitation, but it does not improve social behaviors.

The nurse determines that the son of a client with Alzheimer's disease needs further education about the disease when he makes
which of the following statements?
1. "I didn't realize the deterioration would be so incapacitating."
2. "The Alzheimer's support group has so much good information."
3. "I get tired of the same old stories, but I know it's important for Dad."
4. "I woke up this morning expecting that my old Dad would be back."
4.
The statement about expecting that the old Dad would be back conveys a lack of acceptance of the irreversible nature of the
disease. The statement about not realizing that the deterioration would be so incapacitating is based in reality. The statement
about the Alzheimer's group is based in reality and demonstrates the son's involvement with managing the disease. Stating that
reminiscing is important reflects a realistic interpretation on the son's part.

The husband of a client with Alzheimer's disease that was diagnosed 6 years ago approaches the nurse and says, "I'm so excited
that my wife is starting to use donepezil (Aricept) for her illness." The nurse should tell the husband:
1. The medication is effective mostly in the early stages of the illness.
2. The adverse effects of the drug are numerous.
3. The client will attain a functional level of that of 6 years ago.
4. Effectiveness in the terminal phase of the illness is scientifically proven.
1.
When compared with other similar medications, donepezil (Aricept) has fewer adverse effects. Donepezil is effective primarily in
the early stages of the disease. The drug helps to slow the progression of the disease if started in the early stages. After the client
has been diagnosed for 6 years, improvement to the level seen 6 years ago is highly unlikely. Data are not available to support the
drug's effectiveness for clients in the terminal phase of the disease.

The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this
medication to help decrease which of the following behaviors?
1. Sleep disturbances.
2. Concomitant depression.
3. Agitation and assaultiveness.
4. Confusion and withdrawal.
3.
Antipsychotics are most effective with agitation and assaultiveness. Antipsychotics have little effect on sleep disturbances,
concomitant depression, or confusion and withdrawal.
The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam
(Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should
instruct the family to report which of the following significant side effects to the health care provider?
1. Paradoxical excitement.
2. Headache.
3. Slowing of reflexes.
4. Fatigue.
1.
Although all of the side effects listed are possible with Ativan, paradoxical excitement is cause for immediate discontinuation of the
medication. (Paradoxical excitement is the opposite reaction to Ativan than is expected.) The other side effects tend to be minor
and usually are transient.
When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the
following suggestions is most relevant?
1. Allow the client to go to bed four to five times during the day.
2. Test the cognitive functioning of the client several times a day.
3. Provide reality orientation even if the memory loss is severe.
4. Maintain consistency in environment, routine, and caregivers.
4.
Change increases stress. Therefore, the most important and relevant suggestion is to maintain consistency in the client's
environment, routine, and caregivers. Although rest periods are important, going to bed interferes with the sleep-wake cycle. Rest
in a recliner chair is more useful. Testing cognitive functioning and reality orientation are not likely to be successful and may
increase stress if memory loss is severe.

1. The nurse is assessing a teenage patient for suicidal risk. Which patient statement would require immediate
further nursing assessment?
1. "The idea of death really scares me."
2. "I only smoked one time in my life."
3. "My mom keeps a bunch of pills in her nightstand."
4. "I've never tried to kill myself before."
ANS: 3
Rationale: Patients who acknowledge the existence of a plan for suicide or have a demonstrated accessibility to
the method for carrying out the plan should be assessed further. This patient knows where medications are kept,
which indicates there is accessibility for a method to carrying out a plan.

2. The nurse is preparing to assess a child who primarily speaks Spanish but is fluent in English. Which is the
appropriate method for gathering information?
1. Begin the assessment in English.
2. Utilize a Spanish dictionary to ask questions of the child.
3. Ask the child if he understands English.
4. Obtain an interpreter who is fluent in Spanish.
ANS: 4
Rationale: The use of "nonstandard" English dialects can make speech difficult to assess and contribute to
stereotyping. To facilitate accuracy in assessment, a child should be interviewed in his or her native language to
fully understand any problems.

3. The nurse is caring for a 9-year-old patient who will be entering a freedom room. Which activity should the
nurse anticipate the child would engage in?
1. Listening to a CD
2. Throwing pillows
3. Sitting in the periphery of the room
4. Punching soft objects
ANS: 1
Rationale: A freedom room is a type of quiet room that contains items for relaxation and meditation like music
and yoga mats. The child is encouraged to express freely and work through feelings of anger or sadness in
privacy with staff support. Another type of quiet room, the feelings room, is carpeted and supplied with soft
objects that can be punched or thrown. The time-out area is one in which a child can go to sit until self-control is
regained and the episode of behavior can be reviewed with a staff member.
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX Client Needs: Psychosocial Integrity
4. A 7-year-old male who has met earlier normal expectations in cognitive and language development develops
a fascination with the bus schedule in his neighborhood and has difficulty
establishing friendships with other school children. Which condition should the nurse anticipate?
1. Mild autism
2. Severe autism
3. Rhett's disorder
4. Asperger's disorder
ANS: 4
Rationale: While autistic disorders typically appear during a child's first 3 years of life, Asperger's disorder
appears to have a later onset. Individuals with Asperger's disorder often develop idiosyncratic interests and have
problems with social relationships upon entering school. Rhett's disorder is only observed in females, with an
onset before 4 years of age.
Nursing Process: Assessment
Cognitive Level: Application
NCLEX Client Needs: Psychosocial Integrity
5. The nurse is caring for a patient with attention deficit hyperactivity disorder (ADHD). Which medication
order should the nurse question?
1. Strattera (atomoxetine)
2. Lithobid (lithium)
3. Wellbutrin (bupropion)
4. Concerta (methylphenidate)
ANS: 2
Rationale: Patients with attention deficit hyperactivity disorder (ADHD) may be prescribed stimulants (e.g.,
methylphenidate), nonstimulants (e.g., atomoxetine), tricyclic antidepressants (e.g., desipramine), or atypical
antidepressants (e.g., bupropion). Lithium is indicated for bipolar disorder; therefore, the nurse should question
this medication order.

1. Several months ago, a 12-year-old male client was involved in an exploitative homosexual relationship with an older adolescent. Now in therapy, the
client expresses feelings of helplessness and fantasizes about "getting even with the older youth. The child/adolescent psychiatric and mental health
clinical nurse specialist encourages the client to:

engage in activities with boys who are his age.

take karate lessons to learn the skills needed to defend himself.

work out with a punching bag to displace his hostility.

write a letter to the perpetrator, expressing his rage at being exploited.

2. Two child/adolescent psychiatric and mental health clinical nurse specialists are conducting a continuing education class for nurses, psychiatric
technicians, and aides who have varying levels of experience and education. The clinical nurse specialists begin the class by introducing themselves and
relating their backgrounds and experience. The class is then asked to do the same and tell why they are there. This method reflects which principle of
adult learning theory?

Assessment of group dynamics

Assessment of knowledge and learning needs of participants

Establishment of group cohesiveness and rapport with participants

Establishment of the clinical nurse specialists' role as experts

3. After climbing on the trees that surround a six-year-old female childs home, the child reports that the "angry trees" made her fall. This animistic
thinking is:

a coping mechanism to allay the child's guilt feelings.

an abnormal thought process for a child of this age.

characteristic of preoperational thought.

indicative of childhood schizophrenia.

4. For the past 18 months, an eight-year-old child has exhibited involuntary, purposeless, rapid recurrent movements of the arms and face as well as
spontaneous unintelligible vocalizations. When receiving verbal cues, the child can decrease and sometimes extinguish the erratic movements for several
minutes. The diagnosis is:

atypical tic disorder.

chronic motor tic disorder.

stereotypic movement disorder.

Tourette disorder.

5. An eight-year-old female child is referred to the child/adolescent psychiatric and mental health clinical nurse specialist for verbalizing fears that her
immigrant grandmother will die. The widowed grandmother wears heavy black clothes, prays throughout the day, and secludes herself from everyone
except the child. Although the grandmother is physically healthly, she discusses her impending death with the child. The clinical nurse specialist
recognizes that:
cultural factors may negate the significance of seemingly obvious symptoms.

religious fixations are common in delusional systems.

the grandmother and the child communicate only in the grandmother's native language.

the grandmother is exhibiting classic signs of endogenous depression.

6. Which of Yalom's curative factors in group therapy applies to female adolescents who have sustained incest?

Altruism

Group cohesiveness

Imitative behaviors

Universality

7. A child/adolescent psychiatric and mental health clinical nurse specialist on the adolescent unit observes a group of three patients ostracizing a fourth
patient. The members of the group use a special walk and wear similar outfits to define themselves. The clinical nurse specialist realizes that the:

group members must be separated from one another.

group's intolerance serves as a defense against their sense of identity confusion.

ostracized adolescent may not have reached the developmental stage of the others.

ostracized adolescent should be transferred to another unit or discharged.

8. A 17-year-old patient arrives at the emergency department with nonspecific complaints. The patient's temperature is 100.8F (38.2C), pulse rate and
blood pressure are elevated, and pupils are dilated with decreased reaction to light. Two days ago, the patient began taking sertraline (Zoloft) 50 mg daily
for treatment of depression. The patient has a history of substance use and smoked marijuana one week ago. The diagnosis is:

alcohol withdrawal.

infection affecting the central nervous system.

neuroleptic malignant syndrome.

serotonin syndrome.

9. A mother and father who have recently separated are in family therapy with their six-year-old child, who is experiencing behavioral problems. The
father is now involved in a homosexual relationship. During this session, the mother initiates a heated discussion of her fears that the child is being
exposed to age-inappropraite sexual behavior in the fathers home. The child/adolescent psychiatric and mental health clinical nurse specialist's action is
to:

exclude the child from future sessions because of the child's age and cognitive ability.

exclude the child from future sessions because of the sexual content being discussed.

exclude the child from this session because the issues being discussed are inappropriate for the child to hear.

include the child in this session because his or her presence provides useful data for clinical assessment.

10. A child is receiving mental health care in a managed care setting. The child's father questions the confidentiality of the treatment records, fearing that
the information could negatively impact his employment or future insurance coverage. In responding, a child/adolescent psychiatric and mental health
clinical nurse specialist recognizes that the father is:
demonstrating resistance to therapy.

expressing a major concern for patients of managed care systems.

focused on personal, rather than treatment, issues.

having difficulty building a trusting, therapeutic relationship.

11. According to the Diagnostic and Statistical Manual of Mental Disorders, to diagnose attention-deficit hyperactivity disorder, a child/adolescent
psychiatric and mental health clinical nurse specialist assesses a child's:

ability to listen when directly addressed.

ability to remain seated in a classroom.

behavioral functioning, both at home and at school.

intellectual functioning based on psychometric testing.

12. A child/adolescent psychiatric and mental health clinical nurse specialist counsels the parent of a preschool-aged child who has fetal alcohol
syndrome. When asked how to manage the child's excitability, the clinical nurse specialist advises the parent to:

avoid games with repetition of ideas and behaviors.

begin and end each play activity with less action.

increase interactions with other children.

play soft music in the background during play activities.

13. When beginning therapy with a six-year-old child with autism, the child/adolescent psychiatric and mental health clinical nurse specialist initially
communicates with the child:

nonverbally, through facial expressions and simple gestures.

nonverbally, through tactile stimulation.

verbally, by giving full, detailed explanations.

verbally, by using humor and popular children's language.

14. A mother brings her four-year-old son in for evaluation because he


"does not get along with his step-siblings." The mother reports that her son refuses to play a game with his step-siblings unless they play by his rules.
According to cognitive development theory, the explanation for the child's behavior is that he is in the:

developmental stage of industry versus inferiority and he may feel inadequate when competing with older children.

preconventional stage of thinking and his behavior is motivated by egocentrism.

preoperational stage of thinking and it is difficult for him to accept differing viewpoints.

stage of concrete operations.

15. A mother who has paranoid delusions has been isolating her seven-year-old child. The child is developing disruptive behavior and the family has
come to the attention of several community agencies. The most effective means of addressing the family's needs is to:

allow the mother and child to determine their desired level of involvement with the community agencies.

encourage the mother and child to interact with representatives from the various agencies.
focus on a single need and service agency to help manage the anxiety level of the mother and child.

use multiple agencies with a primary clinician to clarify the roles and boundaries and coordinate interventions.

16. A child/adolescent psychiatric and mental health clinical nurse specialist conducts a community meeting for children and adolescent patients. Several
adolescent patients complain about the intrusive behavior of the younger children. The clinical nurse specialist maintains the therapeutic milieu by:

asking both the adolescents and the younger patients to provide solutions.

giving the younger patients room restrictions.

reviewing with the group the rules and consequences of intrusive behaviors.

scheduling a meeting with the adolescent patients and nurse manager for later in the day.

17. When conducting a longitudinal non-experimental study about various modalities to treat bipolar disorder in children and adolescents, a
child/adolescent psychiatric and mental health clinical nurse specialist:

chooses two types of randomly assigned treatment.

evaluates each child and adolescent research participant every six months for five years.

initiates several clinical trials under strict criteria.

sets up a comparison group of patients who will not receive any treatment for a two-year period.

18. The director of psychiatric services asks a child/adolescent psychiatric and mental health clinical nurse specialist to define and coordinate the
standard of nursing care for psychiatric patients in the emergency department. The clinical nurse specialist is serving in the role of a change:

agent.

investigator.

recipient.

strategist.

19. A child/adolecent psychiatric and mental health clinical nurse specialist meets regularly with the staff nurses of an adolescent inpatient psychiatric
unit to improve the nurses' therapeutic interactions with the patients. Each nurse keeps a journal describing clinical interactions with an adolescent and
examines the factors that hinder the nurse's ability to interact therapeutically with the patient. The clinical specialist reviews the entries and provides
written feedback. This teaching strategy is known as:

concept mapping.

discovery learning.

problem-based learning.

reflective practice.

20. An adolescent client states, "My mother doesn't believe that I'm really in pain. She thinks it's all in my head, but I know I feel the pain." The
child/adolescent psychiatric and mental health clinical nurse specialist responds:

Pain is real, whatever the cause. Many physical diseases are partially related to stress."

You never know what is real pain and what is psychological pain until you explore the source."

Your mother may be right. Let's try to figure out if that is the problem in your case."
Your mother thinks that I can help you; that is why you were sent to me."

21. A primary goal of a practice guideline is to:

document preferred practice patterns.

enhance subjective judgments.

expand access to care.

support expert opinion.

22. Dysregulation of gamma-aminobutyric acid is associated with a diagnosis of:

anxiety disorder.

delirium.

Huntington disease.

schizophrenia.

23. A child/adolescent psychiatric and mental health clinical nurse specialist learns that a patient with bipolar affective disorder is moving out of state.
The clinical nurse specialist refers the patient to a new provider for a followup appointment and prescribes enough medication to last until the
appointment with the new clinical nurse specialist. These actions demonstrate the clinical nurse specialist's understanding of the:

disease process of bipolar affective disorder.

laws related to patient abandonment.

length of time needed to schedule a new appointment.

standards of practice.

24. The parent or legal guardian of a seven-year-old child must approve any medication orders, because a child of this age fails to meet which two of the
four elements of informed consent?

Autonomy and veracity

Competence and comprehension

Confidentiality and beneficience

Disclosure of information and voluntariness

25. The adolescent parents of a three-year-old child attend an alternate high school that houses an onsite daycare center. The school nurse refers the
parents to a child/adolescent psychiatric and mental health clinical nurse specialist to help them manage their child's temper tantrums. The focus of the
treatment plan is a:

behavior modification program for the child that the parents will implement at home.

parenting class at a local mental health clinic for the parents to attend weekly during the evening.

play therapy session for the child, which the clinical nurse specialist conducts weekly.

school-based intervention with the parents to convey that behavior is motivated by thoughts and feelings.