A family member brought a senior to the clinic. The family member explained to the nurse that the patient suddenly from one day to the other, started with confusion, and agitation. The family states the patient used to be orientated and with very calm behavior. The nurse suspects that this patient is experiencing:
Delirium
Sundowning
Alzheimers
Dementia
The Correct Answer is A
A. Delirium: Delirium is characterized by a sudden onset of confusion, agitation, and fluctuating levels of consciousness. It often develops over a short period, such as hours to days, and is typically associated with an underlying medical condition, medication, or infection. The patient's rapid change from being oriented and calm to confused and agitated suggests a sudden onset, which is indicative of delirium.
B. Sundowning: Sundowning refers to a pattern of increased confusion and agitation that occurs in the late afternoon or evening, primarily in individuals with dementia. While it involves fluctuations in mental status, it does not usually present with a sudden onset of symptoms as described in this case.
C. Alzheimer’s: Alzheimer’s disease is a form of chronic dementia characterized by gradual and progressive cognitive decline over months to years. The sudden onset of confusion and agitation does not align with the gradual progression typical of Alzheimer's disease.
D. Dementia: Dementia is a general term for a decline in cognitive ability that affects daily life, usually developing gradually over time. Unlike delirium, dementia does not present with a sudden change in behavior or mental status, making it less likely in this scenario where the change was abrupt.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Pectoralis major tear: A tear of the pectoralis major muscle would likely cause pain and weakness, particularly in activities involving pushing or lifting. While it may affect shoulder movements, it is less likely to specifically impair the ability to reach behind the back and touch the shoulder blade compared to rotator cuff issues.
B) Arthritis: Arthritis, particularly osteoarthritis, can cause decreased range of motion and pain in the shoulder joint. However, the specific movement described—placing one hand behind the back to touch the shoulder blade—is most commonly affected by issues with the rotator cuff rather than arthritis alone.
C) Rotator Cuff Tendinitis: Rotator cuff tendinitis is a common cause of shoulder pain and decreased range of motion, particularly affecting movements that require lifting the arm or reaching behind the back. Tendinitis in the rotator cuff can lead to pain and difficulty performing the movement described due to inflammation and impingement of the tendons.
D) Gout: Gout is a type of arthritis caused by the accumulation of uric acid crystals in the joints, often affecting the big toe but can affect other joints. While it can cause joint pain and inflammation, it is less likely to specifically impair the shoulder movement described compared to rotator cuff tendinitis.
Correct Answer is ["A","C","D"]
Explanation
A. Weber test: The Weber test is used to assess hearing by placing a vibrating tuning fork on the center of the forehead. It helps evaluate lateralization of sound and can indicate whether hearing loss is conductive or sensorineural. This test is pertinent for assessing CN VIII, which is responsible for hearing.
B. Magazine: This option is not relevant to the assessment of CN VIII. A magazine is not used in evaluating hearing or vestibular function. The appropriate assessments for CN VIII focus on hearing and balance.
C. Rinne test: The Rinne test involves placing a vibrating tuning fork on the mastoid bone and then near the ear canal to compare air conduction (AC) and bone conduction (BC) of sound. This test helps differentiate between conductive and sensorineural hearing loss and is directly related to assessing CN VIII.
D. Whispered voice test: This test involves the nurse whispering numbers or words while occluding one ear and assessing the client's ability to hear and repeat them. It is a simple way to assess hearing ability and thus evaluates the function of CN VIII.
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