question

*Explain Delirium?

answer

-mild neurocognitive disorders -short term and reversible -acute cognitive disturbance -cardinal symptoms: alteration in level of consciousness, altered awareness and inability to direct, focus, sustain, and shift attention, periods of lucidity, disorganized, thinking, and poor executive functioning -others: disorientation to time and place, anxiety, agitation, restlessness, poor memory recall, delusional thinking, hallucinations (visual) or tactile and illusions -sudden change I reality with a sense that they are dreaming while awake -experience dramatic scenes that engender strong feelings of fear, panic, and anger -considered medical emergency requires immediate attention to prevent serious damage -in pts with pretexting cognitive impairment (dementia) there is an acceleration of cognitive decline (can have long term consequences) -depression can be found post delirium *early detection of delirium is crucial -disorientation and confusion are usually worse at night and during early morning

question

What is the most common complication of hospitalization in older patients?

answer

delirium

question

*What are predisposing factors for delirium?

answer

age, lower education, sensory impairment, decreased functional status, comorbid medical conditions, malnutrition, and depression

question

*What are the 4 cardinal features of delirium?

answer

1. acute onset and fluctuating course 2. reduced ability to direct, focus, shift, and sustain attention 3. disorganized thinking 4. disturbance of consciousness (suspect delirium when the pt abruptly develops a disturbance in consciousness and he ability to focus, sustain, or shift attention is impaired)

question

Explain illusions?

answer

-mistake folds in the bedclothes for white rats or the cord of a window blind for a snake -misinterprets an object of the pt's projected fear -illusions unlike delusions hallucinations can be explained and clarified

question

*What type of hallucinations are common in delirium?

answer

visual and tactile. Illusions are also common

question

*Explain Physical Needs for the pt with delirium?

answer

- may try t0 go home -wandering, pulling out IV lines and catheters, and falling out of bed are common dangers -difficulty processing the environment -the environment should be made simple and clear -objects such as clocks and calendars can maximize orientation to time -glasses, hearing aids, and adequate lighting without glare can maximize the person's ability to interpret what is going on -short periods of social interaction can help decrease anxiety -LOC alternates from lethargy to stupor or from semi-coma to hypervigilance (pts are extremely alert, eyes constantly scan the room, difficulty falling asleep or agitated throughout the night) -Autonomic signs present in delirium: tachycardia, sweating, flushed face, dilated pupils, elevated BP

question

*What should always be suspected as a potential cause of delirium?

answer

medications

question

*What are Moods and Physical Behaviors of delirium?

answer

-pt may alternate between agitation and appear calm and settled -agitation delirium: hyperactive -no agitation: delirium is hypoactive -pt may cry, call for help, strike out -pt may have euphoria, or depression, and apathy -behaviors and emotions are erratic and fluctuating -pts can recall sometimes their confused state after delirium subsides -anxiety and fear can remain with them for months after delirium has gone away *pts with acute delirium should never be left alone (family membered can help stay with the pt if the nurse cannot)

question

What are Assessment guidelines when caring for the pt with delirium?

answer

-assess for acute onset and fluctuating levels of awareness -asses pts ability to attend to immediate environment -establish pts normal LOC -asses for pts cognitive impairment such as existing dementia dx -asses potential for injury such falls and wandering *remember that if the underlying cause of delirium is not treated, permanent brain damage may occur (antipsychotics and antianxiety meds may help control behavioral symptoms)

question

*Explain Interventions for Delirium Management?

answer

-make sure environment is safe -reduce or eliminate factors causing delirium -use physical restraints are needed -provide positive regard -administer meds for anxiety or agitation as needed -provide pt with info about what is happening and what can be expected -limit need for decision making, if pt is frustrated or confused -inform pt of person, place, and time as needed -approach pt slowly and from the front and address pt by name -reorient pt by using sings, pictures, clocks, calendars, and color coding of environment to provide stimulation of memory, and promote appropriate behavior -provide low stimulation environment -encourage use of aids that increase sensory input such as glasses, hearing aids, and dentures

question

*Explain Dementia?

answer

-progressive deterioration of cognitive functioning with no change in consciousness -collection of symptoms that are due to an underlying brain disorder -mild forms d not interfere with activities of daily living -dementia affects memory, problem solving and complex attention -Alzheimer's disease is the most common type -dementia is marked by progressive deterioration in cognitive functioning and the ability to solve problems and learn new skills and by a decline in the ability to perform activities of daily living -pts with dementia can have anxiety, mood lability and depression, as well as hallucinations and delusions -classified as mild or major (substantial decline that curtails the pts independence and functioning) signs: poor judgment and decision making, inability to manage a budget, losing track of the date or the season, difficulty having a conversation, misplacing things and being unable to retrace steps to find them

question

*What are the several types of dementia?

answer

-dementia is associated with AD, frontotemporal lobar degeneration, Lewy bodies, vascular issues, traumatic brain injury, HIV infection, Prion disease, Parkinson's disease, and Huntington's disease

question

*What are signs of dementia?

answer

poor judgment and decision making, inability to manage a budget, losing track of the date or the season, difficulty having a conversation, misplacing

question

What are risk factors for Alzheimer's disease?

answer

-cardiovascular disease, obesity, sedentary lifestyle, inactivity, diabetes, inactivity, high cholesterol, brain injury and trauma (boxers and football players)

question

*Explain Alzheimer's disease?

answer

-type of dementia -progressive deterioration of cognitive functioning -initial deterioration may be so subtle that others may not notice -in early phases some pts are able to hide severe deficits in memory -pt may have defense mechanisms including denial, confabulation (creation of stories or answers in place of actual memories to maintain self esteem), perseveration (repeating of phrases or behavior), and avoidance of questions Ex of Confabulation: when asked how was your weekend, pt might say, "S pent the weekend with my daughter or I discussed politics with the president." It is an unconscious attempt to maintain self esteem Ex of Perseveration: repetition of phrases or behavior which is eventually seen and is often intensified under stress

question

*What are symptoms observed in AD?

answer

-memory impairments: initially pt has difficulty remembering recent events -disturbances in executive functioning: (planning, organizing, abstract thinking) -Aphasia (loss of language ability): initially pt has problem finding correct word, then is reduced to a few words, and finally reduced to babbling or mutism -Apraxia (loss of purposeful movement in the absence of motor or sensory impairment): unable to perform purposeful tasks. Ex: apraxia of dressing, pt is unable to put clothes on properly (arms in trousers or put a jacket on upside down). -Agnosia (loss of sensory ability to recognize object): pt may lose ability to recognize familiar sounds (auditory agnosia), such as the ring ot the phone. Loss of this ability extends to the inability to recognize familiar objects (visual or tactile agnosia) such as a glass, magazine, pencil, or toothbrush

question

A patient with dementia is unable to name ordinary objects. Instead, he describes the function, for example, "the thing you cut meat with." The nurse should assess this as: A. apraxia. B. agnosia. C. aphasia. D. amnesia

answer

B. agnosia. ◦Rationale: Agnosia is the failure to identify objects despite intact sensory function. 1. Apraxia is the inability to carry out purposeful, complex movements and use objects properly. 3. Aphasia refers to inability to speak (expressive) or inability to comprehend what is said or written (receptive). 4. Amnesia is inability to remember a significant block of information.

question

Which of the following descriptions of patient experience and behavior can be assessed as an illusion? A patient A. states, "I keep hearing a man's voice telling me to run away." B. looks at the shadows on a wall and tells the nurse she sees frightening faces on the wall. C. becomes anxious whenever the nurse leaves her bedside. D. tries to hit the nurse when vital signs are being taken.

answer

B. looks at the shadows on a wall and tells the nurse she sees frightening faces on the wall.

question

Which of the following would the nurse assess as an example of cognitive impairment? A. Crying when the occasion calls for laughter B. Inability to name a familiar object C. Incontinence D. Agitation

answer

B. Inability to name a familiar object Rationale: Inability to name an object is called agnosia. Naming an object requires a high level of cortical functioning. Agnosia is an example of cognitive impairment. An illusion is a misinterpreted sensory perception.

question

An action the nurse can advise a family to take in the home setting to enhance safety for the family member with Alzheimer's disease is A. placing throw rugs on tile or wooden floors. B. instructing patient on cooking safety. C. allowing patient to smoke unattended. D. having patient wear an identification bracelet with name, address, and telephone number

answer

D. having patient wear an identification bracelet with name, address, and telephone number

question

With respect to evaluation of outcomes and goals for the patient with Alzheimer's disease, the nurse should be aware of the need for A. changing expectations for the patient as patient abilities deteriorate. B. identifying stressors that impact negatively on the patient. C. simplifying the environment to reduce sensory perceptual alterations. D. changing interventions when goals are unmet.

answer

A. changing expectations for the patient as patient abilities deteriorate. Rationale: A patient whose course of illness is predictably downward will need to have goals and outcomes correspondingly adjusted to lower levels. This is true of a patient with Alzheimer's disease. Option 1 is the only one that deals with goal and outcome planning. Option 2 deals with assessment, and options 3 and 4 deal with interventions.

question

Which of the following is an appropriate nursing intervention for a patient with dementia who develops a catastrophic reaction? A. Employ negative responses to the behavior. B. Use touch to communicate. C. Eliminate or reduce environmental stimulation. D.Maintain close personal boundaries.

answer

C. Eliminate or reduce environmental stimulation.

question

The husband of a patient with moderately advanced Alzheimer's disease tells the nurse his wife becomes greatly distressed several times a week as she tells him she sees strangers walking around in the house. She thinks these strangers are taking her things. The nurse should advise the husband to: A. try to talk his wife out of these ideas by using logic. B. try diverting her by suggesting an activity. C. search the house with her and show her that no strangers are there. D. put locks on doors and windows to increase her sense of security.

answer

B. try diverting her by suggesting an activity.

question

An objective sign that frequently accompanies the subjective symptoms of delirium is: A. reduced awareness. B. disorganized thinking. C. psychomotor retardation. D. disturbed sleep-wake cycle

answer

D. disturbed sleep-wake cycle D. disturbed sleep-wake cycle Rationale: Patients with delirium often demonstrate day-night sleep reversal. Regarding option 1, awareness fluctuates. Regarding option 2, thinking matches level of awareness, with logical alternating with illogical. Regarding option 3, psychomotor agitation is often seen as plucking at the bed sheets or nightgown.

question

Which of the following nursing techniques are appropriate for successful interaction with a patient who has been diagnosed with Alzheimer's disease A. Giving all directions at one time to increase understanding B. Correcting errors made by the patient by speaking to him in a loud, clear voice C. Encouraging communication and maintaining a calm demeanor D. Setting strict time limits and repeatedly rephrasing misunderstood questions

answer

C. Encouraging communication and maintaining a calm demeanor Rationale: These interventions will create a positive emotional climate and preserve patient self esteem. 1. Directions should be given in step-by-step fashion. 2. Activities should not be judged, and the patient should be addressed in a well-modulated voice. 4. Patients with dementia usually need increased time to perform a task, and direction should not be rephrased, only repeated.

question

The nurse notes that an elderly patient has fluctuating levels of awareness. She seems anxious. She tells the nurse she saw her granddaughter standing at the foot of the bed during the night. Later the nurse sees her moving her hands as though picking things out of the air. The nurse should suspect: A. delirium. B. dementia. C. bipolar disorder. D. schizophrenia

answer

A. delirium.

question

When the nurse gives anticipatory guidance to the family of a patient with early Alzheimer's disease, which behavioral problem common to that stage of the disease should be mentioned? A. Violent outbursts B. Emotional disinhibition C. Inability to carry on an in-depth conversation D. Inability to eat and drink enough to meet body requirements

answer

C. Inability to carry on an in-depth conversation Rationale: Families should be made aware that the patient will have difficulty concentrating and following or carrying on in-depth or lengthy conversations. The other symptoms are usually seen at later stages of the disease.

question

Which of the following patients is at highest risk of developing dehydration?

answer

A 78-year old patient with dementia

question

A 75-year-old patient who has vision and hearing problems has a history of striking out at caregivers. Which of the following is the most appropriate nursing intervention?

answer

Get the patient's attention and consent before starting care.

question

To evaluate thoroughly an older patient's memory, it is helpful to use reminiscence strategies because they:

answer

Stimulate memory chain through associations.

question

Aricept (donepezil) is an Alzheimer's medication and is expected to do what? enhance the concentration of ___ in the brain, thus improve ________ ______.

answer

◦-Acetylcholine ◦-cognitive functioning

question

What is it called when the loss of the ability to recognize or identify familiar objects?

answer

Agnosia

question

What is it when you're unable to perform previously known motor activities?

answer

Apraxia

question

What types of drugs should be avoided in persons with dementia, as it can interfere with learning & might decrease cognitive abilities further?

answer

Benzodiazepines (ie. Valium)

question

*Briefly describe some important factors about Delirium?

answer

-onset is sudden -can be caused by hypoglycemia, fever, dehydration, hypotension, infection, adverse drug reaction, head injury, change in environment (hospital), pain, stress -cognitive impaired memory, judgment, attention span can fluctuate throughout the day -LOC is altered -activity is increased or reduced, restlessness, worse in evening (sundowning), sleep/wake cycle may be reversed -pt has rapid emotional swings, fearful, anxious, suspicious, aggressive, hallucinations, or delusions -speech and language is rapid, inappropriate, incoherent, rambling -prognosis can be reversible with proper and timely treatment

question

*Briefly explain important factors about Dementia?

answer

-onset is slow, over months -caused by Alzheimer's disease, HIV infection, neurological disease, chronic alcoholism, head trauma -cognition is impaired memory, judgment, attention pan, abstract thinking, agnosia -LOC not altered -activity level not altered, behaviors may worse in evening (sundowning) -emotional state is flat; agitation -speech and language is incoherent, slow (effort to find right word), inappropriate, rambling, repetitious -prognosis is not reversible and progressive

question

*Briefly explain important factors about Depression?

answer

-onset may be gradual, with exacerbation during crisis or stress -causes include lifelong hx, losses, loneliness, crises, declining health, medical conditions -cognition in that pt has difficulty concentration, forgetfulness, inattention -LOC not altered -activity level is usually decreased, lethargic, fatigue, lack of motivation, may sleep poorly and awaken in early morning -emotional state includes extreme sadness, apathy, irritability, anxiety, paranoid ideation -speech is slow, flat, low -prognosis can be reversible with proper and timely treatment

question

Explain Mild cognitive impairment due to Alzheimer's disease?

answer

-pt loses energy, drive, and initiative and has difficulty learning new things -depression ma occur early in the disease -as AD progresses pt is often unable to identify familiar objects or people, even spouse (agnosia) -pt needs repeated instructions and directions to perform the simplest tasks (apraxia) -when AD progresses to the point that the person cannot take care of themselves they can become agitated, violent, paranoid, and delusional because the world is frightening -wandering behavior also occurs

question

Explain what behaviors occur late in Alzheimer's disease?

answer

-agraphia (inability to read and write) -hyperorality (need to taste, chew, and put everything in one's mouth) -blunting of emotions -visual agnosia (loss of ability to recognize familiar objects) -hypermetamorphosis (touching everything in site)

question

*Explain stage 1 and Stage 2 of Alzheimer's disease?

answer

Stage 1: no impairment. No memory problems Stage 2: very mild cognitive decline (may be age-related or due to dementia). Pts forget familiar words or location of everyday objects. No s/s of dementia can be detected during a medical exam or by friends, or family

question

*Explain stage 3 and Stage 4 of Alzheimer's disease?

answer

Stage 3: mild cognitive decline (early-stage Alzheimer's can be diagnosed in some with s/s). Other begin to notice. Problems coming up with right word or name. Trouble remembering names when introduced to people. Difficulties performing tasks in social or at work. Forgetting material one has just read. Losing or misplacing an object. Increasing trouble with placing or organizing. Forgetfulness of recent events Stage 4: moderate cognitive decline (mild or early-stage Alzheimer's disease). Impaired ability to perform challenging mental arithmetic. Difficulty performing complex tasks such as planning inner, paying bills, or managing finances. Pt becomes moody or withdrawn especially in social or mentally challenging situations

question

Difficulty paying bills or managing finances occurs in which stage of Alzheimer's disease?

answer

Sage 4

question

*Explain stage 5 and Stage 6 of Alzheimer's disease?

answer

Stage 5: moderately severe cognitive decline (moderate or midstage Alzheimer's disease). Gaps in memory and thinking are noticeable, and pts begin to need help with day-today activities. A this stage, pts may be unable to recall their own address or telephone numbers or the high schools or colleges from which they graduated. They become confused about where they are or what day it is. Have trouble with less challenging mental arithmetic, need help choosing proper clothing for the season or the occasion. Still remember significant details about themselves and their families. Still require no assistance with eating or using the toilet. Stage 6: severe cognitive decline (moderately severe or midstage Alzheimer's disease). Personality changes may take place, and suffers may need hel with daily activities. At this stage pts may lose awareness of recent experiences as well as their surroundings, remember their own names but have difficult with their personal histories. Distinguish familiar and unfamiliar faces but have trouble remembering the name of a spouse or caregiver. Need help dressing properly and may make mistakes such as putting pajamas over daytime clothes or shoes on the wrong feet. Experience major changes in sleep patterns (sleeping during the day, restlessness at night). Need help with toileting, have trouble controlling their bladder or bowels, experience behavioral changes such as suspiciousness and delusions or compulsive repetitive behavior. Tend to wander or become lost

question

At which stage of Alzheimer's disease do pts become confused about where they are or what day it is, need help with choosing proper clothing to wear, but still remember significant details about themselves and their families?

answer

Stage 5 (can still eat and use toilet on their own)

question

At which stage of Alzheimer's disease does the pt need help with toileting, accidently place the wrong clothes or shoes on, tends to wander, may remember own name and may be able to distinguish familiar and familiar faces, but does not remember names of others including spouses, and loses awareness of their own surroundings?

answer

Stage 6

question

*Explain stage 7 of Alzheimer's disease?

answer

Stage 7: very severe cognitive decline (severe or late-stage Alzheimer's disease). Pts lose the ability to respond to their environment, to carry on a conversation, and eventually to control movement. May still say words or phrases. Pts need help with much of their daily personal care, including earing and using the toilet. They may also lose the ability to smile, sit without support, and hold their heads up. Reflexes become abnormal, muscle grow rigid, swallowing is impaired

question

What are assessment guidelines for dementia?

answer

-evaluate current level of cognitive and daily functioning -identity the needs of the family for teaching and guidance on how to mange catastrophic reaction, lability of mood, aggressive behaviors, and nocturnal delirium and increased confusion and agitation at night (sundowning) -safety is the most important concern when caring for these individuals

question

*Explain some nursing interventions for the pt with Dementia?

answer

-provide rest periods -monitor nutrition and weight -place identification bracelet on pt -address pt by name and speak slowly -give one simple direction at a time -use distraction to manage behavior -provide consistent caregivers, physical environment, and daily routine -provide a low-stimulation environment with adequate lighting -provides cues such as current events, seasons, location, and names to assist orientation -eta pt at small table in groups of three to five for meals -provide finger foods -limit number of choices pt has to make so as not to cause anxiety -place pts name in large block letters in room and on clothing as needed -use symbols rather than written signs to assist pt in locating groom, bathroom or other area

question

*Guidelines for communication with pts with dementia?

answer

-speak slowly -use short, simple words and phrases -maintain face to ace eye contact -be near person when talking -focus on one piece of information at a time -talk with pt about familiar and meaningful things -encourage reminiscing about happy times in life -acknowledge pts delusions and reinforce reality. Do not argue -if pt gets into argument, stop argument and temporally separate those involved. After short while (5 min), explain to each pt matte of factly why you had to intervene -when pt becomes verbally aggressive, acknowledge pts feelings and shift the topic to more familiar ground ("I know this is upsetting for you because you always cared for others. Tell me about your children.") -have pt wear glasses or hearing aids -keep room well lit -have clicks, calendars, and personal items in clear view while he or she is in bed -reinforce pictures, calendars to anchor pt in reality

question

Explain pt and family teaching guidelines for the pt with dementia?

answer

Dressing and Bathing: always have pt wear own clothes even if in hospital, use clothing with elastic and substitute fastening tape (velcro0 for buttons and zippers, give step by step instructions, if pt is resistant to performing self-care, come back later and ask again Nutrition: monitor food and fluid intake, offer finger food that the pt can take away from the dinner table, weigh pt regularly once a week, during periods of hyperorality (make sure they don't eat nonfood items) Bowel and Bladder Function: begin bowel and bladder program early, start with bladder control, label bathroom door Sleep: keep area well lit at night, maintain calm atmosphere during the day, if meds are indicated, consider neuroleptics with sedative properties (Haldol), avoid use of restraints

question

Explain Pharmacological Interventions for AD?

answer

-Donepezil (Aricept) drug of choice for AD because its once per day dosing and few side effects -Cholinesterase Inhibitors: used to improve cognition, behavior function. Slows progression Donepezil (Acricept) Galantamine (Razadyne) -Antipsychotics: used for paranoid thinking, hallucination, agitation Zyprexa Risperdal -Anticonvulsants: for agitated and aggressive behavior and emotional lability Carbamazepine (Tegretol) Divalproex (Depakote) -Antianxiety: treats anxiety restlessness, verbally disruptive behavior, and resistance Lorazepam (Ativan) Oxazepam (Serax) -Galantamine (Razadyne) is prescribed in the first and second stages of AD) -Memantine (Namenda) is prescribed for symptoms found in moderate to severe stages of the disorder

question

What are some interventions for wandering for the pt with dementia?

answer

-if pt wanders at night, keep mattress on floor (prevents falls) -have pt were a medical alert bracelet that cannot be removed. Provide police department with recent pictures -if pt is in the hospital, have them wear brightly colored best with name, unit, and phone number printed on the back, put complex locks on door, and place locks at top of door (ability to look up and reach upward is lost in moderate and late AD), encourage physical activity during the day, install sensory devices

question

Which disorder is always secondary to an underlying condition and is therefore temporary, transient, and may last from hours to days once the underlying cause is treated?

answer

delirium

question

Primary dementia is what?

answer

irreversible Ex: AD

question

What is the most dominant and most disruptive symptoms of dementia?

answer

disorientation

question

Which drugs should be avoided in the patient with dementia?

answer

-Benzodiazepine drugs like Valium (diazepam) should be avoided -These drugs can interfere with learning, and might decrease cognitive abilities further

question

Which medication can be given to help decrease the confusion and agitation that occurs at night (sundowning) in pts with dementia?

answer

Haldol (haloperidol)

question

Inability to move voluntarily, weight loss, vacant stare, and language impairment all reflect which stage of dementia?

answer

end stage

question

When someone copes with a stressful situation by analyzing the situation and "being strong," the defense mechanism of ___________ is being used.

answer

intellectualization (avoid painful emotions associated with a disturbing situation)

question

Difficulty remembering names when introduced to people, difficulties performing tasks in social or at work. Forgetting material one has just read (forgetting recent events) characterizes what stage of AD?

answer

Stage 3

question

Difficulty performing complex tasks such as planning inner, paying bills, or managing finances characterizes which stage of AD?

answer

Stage 4

question

Mild or early-stage Alzheimer's disease with moderate cognitive decline is what stage?

answer

Stage 4

question

Early-stage Alzheimer's disease with mild cognitive decline is what stage?

answer

Stage 3

question

At what stage of AD is it when the pt tends to wander and has suspiciousness and delusions or compulsive repetitive behavior?

answer

Stage 6

question

At what stage of AD is it when the pt needs help with toileting?

answer

Stage 6

question

What stage of AD is it when the pt needs help dressing properly and may make mistakes such as putting pajamas over daytime clothes or shoes on the wrong feet. Experience major changes in sleep patterns (sleeping during the day, restlessness at night)?

answer

Stage 6

question

Moderately severe or midstage Alzheimer's disease is what stage?

answer

Stage 6

question

Moderate or midstage Alzheimer's disease is what stage?

answer

Stage 5

question

"Spent the weekend with my daughter or I discussed politics with the president." Is an example of what?

answer

Confabulation It is an unconscious attempt to maintain self esteem

question

Mild or early stage Alzheimer's disease?

answer

stage 4

question

Early-stage Alzheimer's is which stage?

answer

stage 3

question

1. Which of the following interventions should the nurse incorporate in the care plan of a patient with dementia to support short-term memory? A. Daily activity schedule B. Activities using large muscles C. Simple word games D. A discussion group

answer

A. Daily activity schedule ◦Rationale: A daily activity schedule helps remind the patient of what to do and when to do it. A written schedule helps support recent memory. Options 2, 3, and 4 are appropriate activities but do not directly address the support of recent memory.

question

A 45-year-old male has been admitted with a diagnosis of delirium of unknown etiology. The nurse would expect to assess: A. fluctuating level of consciousness. B. gait abnormalities. C. apathetic affect. D. negative thought content.

answer

A. fluctuating level of consciousness. ◦Rationale: Disturbances of consciousness that tend to fluctuate during the course of the day are a primary symptom of delirium. The other options are not expected in delirium.

question

A patient with dementia is unable to name ordinary objects. Instead, he describes the function, for example, "the thing you cut meat with." The nurse should assess this as: A. apraxia. B. agnosia. C. aphasia. D. amnesia

answer

B. agnosia. ◦Rationale: Agnosia is the failure to identify objects despite intact sensory function. 1. Apraxia is the inability to carry out purposeful, complex movements and use objects properly. 3. Aphasia refers to inability to speak (expressive) or inability to comprehend what is said or written (receptive). 4. Amnesia is inability to remember a significant block of information.

question

Which of the following descriptions of patient experience and behavior can be assessed as an illusion? A patient A. states, "I keep hearing a man's voice telling me to run away." B. looks at the shadows on a wall and tells the nurse she sees frightening faces on the wall. C. becomes anxious whenever the nurse leaves her bedside. D. tries to hit the nurse when vital signs are being taken.

answer

B. looks at the shadows on a wall and tells the nurse she sees frightening faces on the wall. ◦Rationale: An illusion is a misinterpreted sensory perception.

question

Which of the following is an appropriate nursing intervention for a patient with dementia who develops a catastrophic reaction? A. Employ negative responses to the behavior. B. Use touch to communicate. C. Eliminate or reduce environmental stimulation. D. Maintain close personal boundaries.

answer

C. Eliminate or reduce environmental stimulation. ◦Rationale: Reducing stimulation is calming and will allow the patient to focus his or her limited intellectual skills on regaining control. 1. Behavioral responses to the patient should be positive. 2. Touch can easily be misinterpreted as a threat. 4. Patients need increased personal space during catastrophic reactions.

question

Which of the following nursing techniques are appropriate for successful interaction with a patient who has been diagnosed with Alzheimer's disease A. Giving all directions at one time to increase understanding B. Correcting errors made by the patient by speaking to him in a loud, clear voice C. Encouraging communication and maintaining a calm demeanor D. Setting strict time limits and repeatedly rephrasing misunderstood questions

answer

C. Encouraging communication and maintaining a calm demeanor ◦Rationale: These interventions will create a positive emotional climate and preserve patient self esteem. 1. Directions should be given in step-by-step fashion. 2. Activities should not be judged, and the patient should be addressed in a well-modulated voice. 4. Patients with dementia usually need increased time to perform a task, and direction should not be rephrased, only repeated.

question

A patient with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members?

answer

Focus interaction on familiar topics

question

An elderly patient is admitted with delirium secondary to a urinary tract infection. The family asks whether the patient will ever recover. Select the nurse's best response.

answer

"The confusion will probably get better as we treat the infection."

question

An elderly person presents with symptoms of delirium. The family reports, "Everything was fine until yesterday." What is the most important assessment information for the nurse to gather?

answer

A list of all medications the person currently takes

question

a

answer

a

question

a

answer

a

question

A patient with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Place large clocks and calendars strategically.

answer

b. Focus interaction on familiar topics.

question

An 89-year-old man with Alzheimer's disease wanders around the unit disturbing other patients. Which of the following actions by the nurse would be MOST appropriate? 1. Call the physician for an order for a tranquilizer. 2. Place the patient in a geri chair with a clipboard to complete a puzzle. 3. Allow the patient to assist the staff to sort the linen. 4. Explain to the patient that he may not leave his room.

answer

3) CORRECT— keeps patient active and independent, structures his environment, promotes socialization, orients him and preserves his dignity; does not block his wandering behaviors but uses them constructively; it also protects others from intrusion

question

The psychiatric home health nurse visits the home of a patient diagnosed with middle-stage Alzheimer's disease. The patient lives with his daughter and son-in-law, who both insist he stay with them for as long as possible. Which of the following observations MOST concerns the nurse? 1. There are extension cords on the floors behind furniture. 2. There is a bowl of artificial fruit on a glass coffee table. 3. There is a blow-dryer on a hook on the bathroom wall. 4. The door locks are at the tops of the doors

answer

(3.) CORRECT—the dryer itself could be hazardous to this patient in terms of misperceptions of what it is—e.g., a gun—or in terms of improper use causing burns or other injuries; also, having it in bathroom can increase potential for electric shock by patient having contact with water while holding the device when it is turned on

question

The nurse admits a 75-year-old client diagnosed in the early stage of Alzheimer's disease. The nurse should assess for which of the following symptoms? 1. Increased muscle tone and rigidity. 2. Restlessness and pacing. 3. Extension of the head and neck. 4. Shuffling gait.

answer

2) CORRECT— symptoms of early-stage Alzheimer's include recent memory loss and changes in motor activity, such as continuous pacing, wandering, and agitation

question

You are caring for Maggie, a 78-year-old with Alzheimer's disease and Stage III breast cancer who can no longer communicate verbally. What is the appropriate way to assess Maggie's pain?

answer

The Pain Assessment in Advanced Dementia scale

question

You are caring for Miguel, age 76, who is experiencing delirium. Which nursing response is appropriate when the patient's daughter asks, "Will he ever stop acting like this?"

answer

"Once we know the underlying medical cause of the delirium, we can begin treatment to attempt to reverse the process."

question

Marco, age 83, has dementia and has difficulty feeding himself despite the fact that there is nothing wrong with his motor functions. Which term should the nurse use to document this finding?

answer

Apraxia

question

A nurse suspects a client is experiencing delirium. Which specific assessment information would support this suspicion?

answer

A decreased level of consciousness with intermittent hypervigilance

question

Explain agraphia?

answer

inability to read and write

question

A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying "I'm just getting old!" After the nurse completes a thorough neurologic assessment, which findings would be indicative of Alzheimer's disease? Select all that apply.

answer

B) Difficulty performing familiar tasks, such as placing a telephone call C) Misplacing items, such as putting dish soap in the refrigerator E) Rapid mood swings, from calm to tears, for no apparent reason F) Getting lost in one's own neighborhood

Nursing Care of Clients with Cognitive Disorders – Flashcards

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