MULTIPLE CHOICE
1. The nurse asks an older adult patient to count backward from 100 in increments of three; the
patient counts correctly until the nurse stops the process. Which reason does the nurse
identify as a lik
...
MULTIPLE CHOICE
1. The nurse asks an older adult patient to count backward from 100 in increments of three; the
patient counts correctly until the nurse stops the process. Which reason does the nurse
identify as a likely cause of long periods of hesitation during the process?
1. Normal loss of neurons related to aging
2. Early manifestation of dementia
3. Normal delay in problem solving
4. Result of malnutrition and depression
ANS: 3
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: Identify the effects of aging on the nervous system.
Page: 990
Heading: Aging and the Nervous System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Physiological Adaptation
Cognitive Level: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
Feedback
1 With age, the brain loses neurons. However, it loses only a small percentage of
the total, so this is not the usual cause of mental impairment in older adults.
2 Some forgetfulness and decreased ability to problem solve is expected with
aging, but these manifestations are not indicative of dementia.
3 The patient’s long periods of hesitation are indicative of a normal delay in
problem solving.
4 The long delays during the testing are not indicative of malnutrition and
depression. However, some causes of mental changes include depression,
malnutrition, infections, hypotension, and medication side effects. There is not
enough information in this scenario to identify any of these causes.
PTS: 1 CON: Neurologic Regulation
2. The nurse is providing care for multiple patients. Which patient does the nurse decide to
report immediately to the health care provider (HCP) or the registered nurse (RN)?
1. The patient admitted with dysphagia who choked on a thickened liquid
2. The patient who begins to exhibit lack of coordination and aphasia
3. The patient whose neurologic checks show slight variations over 8 hours
4. The patient who reports tingling in the fingers 1 hour after surgery on the hand
ANS: 2
Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Objective: List data to collect when caring for a patient with a disorder of the nervous
system.Page: 990
Heading: Nursing Assessment of the Neurologic System
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Reduction of Risk Potential
Cognitive Level: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
Feedback
1 After a stroke, a patient with dysphasia is placed on a diet that contains
thickened liquids. It is possible for the patient to occasionally choke; the nurse
will monitor the patient for complications and suggest that the dietitian
reevaluate the patient’s diet.
2 Any sudden change in a patient’s neurologic functioning should be reported
immediately to the HCP or the RN. Rapid intervention may make the
difference between chronic dysfunction and recovery, or even between life and
death for the patient.
3 When a patient is receiving neurologic checks over a period of time, some
slight variations are normal and expected.
4 One hour after surgery on a patient’
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