Chapter 22: Cognitive Responses and Organic Mental Disorders

Chapter 22: Cognitive Responses and Organic Mental Disorders

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. An individual brought to the emergency room fights against the restraints and shouts incoherently. The history reveals that the patient was weak and confused on awakening this morning and soon began “rambling and talking crazy.” A nurse notes that the patient’s skin is flushed and dry. The priority nursing action is to:

ANS:  A

The patient’s history suggests a physiological basis for the cognitive disturbance. Vital signs will tell the nurse more about the patient’s physical condition.

DIF:    Cognitive Level: Application           REF:   Text Page: 429

TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

2. An individual is brought to the emergency room after family reports that the patient awoke confused and began “rambling and talking crazy” about 3 hours ago. The patient strikes out at the staff and shouts, “You’re not going to kill me!” The most likely analysis of this behavior is:

ANS:  B

Defining characteristics of sensory-perceptual alteration are present. For impaired environmental interpretational syndrome to be diagnosed, the confused state must have been present for 3 to 6 months. There is no reported history of a catastrophic event while the presence of the other assessment data makes fear associated with hospitalization a less likely reason for striking out at staff.

DIF:    Cognitive Level: Analysis                REF:   Text Page: 405

TOP:   Nursing Process: Diagnosis|Nursing Process: Analysis

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

3. An individual was brought to the emergency room with impaired cognitive function. The patient’s aggressive behavior and attempts to get out of bed present a safety issue. The nurse should first:

ANS:  B

Reality orientation is generally helpful to patients with cognitive impairment. A patient who is misinterpreting reality should be reoriented by a nurse who uses a calm manner and soothing voice. Reorientation is the least restrictive way of addressing the behaviors. Restraints or holding the patient down would increase agitation; assigning staff to stay with the patient continuously is not appropriate as an initial intervention.

DIF:    Cognitive Level: Analysis                REF:   Text Page: 423

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

4. An individual being treated in the emergency room is found to have flushed, dry skin and sensorium that alternates between clouded and clear. A friend reveals the patient has not voided or ingested food or fluid in 18 hours. When the health care provider diagnoses fever of unknown origin, the plan is to make an effort to orally hydrate before attempting to start an IV line. The intervention most likely to be effective will be:

ANS:  D

The nurse should assume or delegate responsibility for providing fluids hourly. The remaining options are unlikely to result in substantial intake.

DIF:    Cognitive Level: Application           REF:   Text Page: 405

TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort