Chapter 21: Cognitive Impairment

9. Which of the following should the nurse use to assess a nonverbal older adult for delirium? a. Cranial nerves XI and XII b. Confusion Assessment Method c. MMSE-2 d. Controlled Word Association Test

ANS: B The Confusion Assessment Method is a tool for measuring delirium in patients who are intubated or nonverbal. Assessing the accessory (CN XI) and hypoglossal (CN XII) cranial nerves provides clues about the patient's ability to swallow. The nurse uses the Controlled Word Association Test to assess for a neurologic cause of an older adult's cognitive dysfunction. This tool is an index of frontal lobe functioning and provides an assessment of executive function, including the patient's frontal lobe functioning and his or her ability to refrain from distraction and perseveration. The MMSE-2 is a valid and reliable tool to assess cognitive function; however, it is unable to pinpoint discrete areas of neurologic dysfunction.

5. The nurse recognizes which of the following displays may indicate hyperactive delirium? a. Lethargy b. Withdrawn behavior c. Nonpurposeful repetitive movements d. Decreased psychoactive activity

ANS: C Patients with hyperactive delirium often wander and have nonpurposeful repetitive movements. Lethargy and withdrawn behavior are both indicative of hypoactive delirium. Patients with hyperactive delirium have increased psychoactive activity, not decreased.

12. When differentiating the characteristics of depression, delirium, and dementia, the nurse recognized which of the following as an indicator of delirium? a. Sudden onset c. Insidious b. Recent loss d. Life change

ANS: A Delirium can occur suddenly. Recent loss or life changes can precipitate depression. Dementia can be insidious, slow, and occur over the course of several years.

11. Which medication administered for delirium under a controlled environment can reduce the duration and severity of delirium for high-risk patients? a. Haloperidol (Haldol) c. Fluphenazine (Prolixin) b. Thioridazine (Mellaril) d. Chlorpromazine (Thorazine)

ANS: A Haloperidol administered in low doses can help reduce the severity and duration of delirium for high-risk patients after hip surgery; however, haloperidol therapy does not reduce the incidence of delirium in this group. In addition, atypical antipsychotic medications can also be effective when administered in low doses under controlled circumstances. Thioridazine is a typical antipsychotic agent and is not indicated in the prevention of delirium. Fluphenazine is a typical antipsychotic medication and is not indicated in the prevention of delirium. Chlorpromazine is a typical antipsychotic agent and is not indicated in the prevention of delirium.

4. Which assessment parameter should the nurse use to differentiate between delirium and depression in an older adult? a. Orientation c. Course over the morning hours b. Activity d. Psychomotor activity

ANS: A Qualities about the patient's orientation are a good method for the nurse to use for distinguishing between delirium and depression; in delirium, orientation is usually impaired, and in depression, orientation is normal. Activity can vary throughout the day and is not a good indicator. Delirium tends to be worse at night, and depression tends to be worse in the morning. The nurse avoids using qualities about the patient's psychomotor activities to distinguish between delirium and depression in an older adult; psychomotor activities in both disorders are highly variable and make distinctions difficult.

2. At 10 PM, an older male resident attempts to climb over the bedrails. Which intervention should the nurse implement first? a. Talk to the resident about his behavior. b. Call the physician, and ask for a sedative. c. Apply a vest restraint on the resident. d. Get a companion to keep him in the bed.

ANS: A The resident is expressing a need that the nurse can potentially determine with gentle questioning. Pharmacological intervention can be necessary but should not replace careful evaluation and management of the underlying cause. Simply restraining the patient will not address the underlying problem, and the imposition of restraints can trigger delirium. Applying a restraint is the last resort, and the nurse must consider the problems that accompany the application of restraints before doing so. Placing a companion in the room can be an effective method of keeping the resident safe if the companion can determine and meet the resident's needs.

10. An older woman has a wound infection 5 days after a below-the-knee amputation brought about by diabetes mellitus. Which of the following is the nurse's priority intervention to prevent cognitive dysfunction and postoperative complications in this older adult? a. Remove invasive devices as soon as possible. b. Minimize the administration of opioid analgesics. c. Allow for self-care and independent activities. d. Administer short-acting benzodiazepines as needed.

ANS: A To help prevent cognitive dysfunction, postoperative complications, and an increased risk of morbidity and mortality, the nurse recognizes that the risk factors this older adult has for delirium include stressors, infection, and surgery; therefore to prevent cognitive decline and additional postoperative complications, the nurse promptly removes invasive devices such as intravenous infusions, urinary catheters, and wound drains. Removing these devices not only reduces the risk of infection, thromboembolic events, blood loss, injury, and fluid imbalance, but they also serve to promote mobility, promote a sense of control for the patient, and reduce the types of situations that can frighten the patient or that the patient can misinterpret. Poor pain management can contribute to delirium in older patients. A patient with multiple stressors and risk factors for delirium needs additional nursing care and attention to provide a calming, caring therapeutic environment. The nurse must assess the patient's functional status before allowing self-care and independent activities. In addition, this older adult is likely to need extensive physical therapy to maintain mobility. Benzodiazepines are a poor pharmacological choice for older adults for sedation or sleep; they can contribute to delirium, are highly addictive, and can cause rebound insomnia if suddenly withdrawn.

4. The nurse working in a long-term care facility completes her morning assessment on a new postoperative patient and notes a change in cognitive status from the previous day? The nurse recognizes which of the following as a precipitating factor for delirium? (Select all that apply.) a. Major medical treatment c. Admission to long-term care b. Poor sleep habits d. Pharmacological agents

ANS: A, C, D Major medical treatment, admission to long-term care, and pharmacological agents are all precipitating factors for delirium. Changes in surroundings often precipitate delirium. The development of delirium is a result of complex interactions among multiple causes. Delirium can result from the interaction of predisposing factors—vulnerability on the part of the individual as a result of predisposing conditions, such as cognitive impairment, severe illness, and sensory impairment; delirium can also result from precipitating factors and insults—medications, procedures, restraints, and iatrogenic events. Although a single factor (e.g., infection) can trigger an episode of delirium, several co-existing factors are also likely to be present. A highly vulnerable older individual requires a lesser amount of precipitating factors to develop delirium. Poor sleep habits is not a contributing factor in of itself.

2. Which of the following is(are) the risk factors for vascular dementia (VaD) after a stroke? (Select all that apply.) a. Smoking b. Male sex c. Hypertension d. Advancing age e. Hyperlipidemia f. African American

ANS: A, C, E Smoking, hypertension, and hyperlipidemia are all risk factors for VaD after a stroke. Male sex, advancing age, and African-American ancestry are risk factor for VaD.

1. Which types of exercise programs are better for older adults with AD for improving mood and function? (Select all that apply.) a. Balance b. Walking c. Self-paced d. Endurance e. Muscle strength f. Lasting 16 weeks or longer

ANS: A, D, E, F Older adults with AD can benefit from regular exercise as demonstrated by more positive affect and mood, improved function, and less disability. Suitable exercises for older adults with AD include exercises that improve balance. Exercises that improve endurance and exercises for muscle strengthening are also both suitable for the older adult with AD. Research data support the claim that exercise programs lasting 16 weeks can help improve function and mood of older adults with AD. Endurance, strength, and balance exercises help improve patients with AD more than walking. Self-paced exercises are unlikely to be suitable for a patient with AD because of cognitive dysfunction.

8. An older woman is recovering from a bowel resection in the intensive care unit but remains intubated and on a mechanical ventilator. Which of the following should the nurse implement to help prevent delirium in this woman? a. Assess cognition with MMSE-2. b. Provide uninterrupted periods of rest and sleep. c. Maintain adequate sedation and pain management. d. Cover the patient's eyes with protective ophthalmic ointment.

ANS: B Providing uninterrupted periods of rest and sleep is a challenge for the nurse in intensive care. Because of the nature of the patients' illnesses, nurses administer medications and treatments and perform invasive procedures on a 24-hour basis, leaving patients little time for rest. Many patients become delirious in the intensive care unit because the noise, activity, brightness, and disturbance tend to persist around the clock, which contribute to delirium. Patients lose their sources for maintaining orientation and stability; that is, bright lighting at all times, as well as unfamiliar and abrupt increases in noise, can lead to a disruption in the circadian rhythm. In addition, patients in intensive care are more likely to receive multiple medications, and medications that are potentially harmful can aggravate the patient's cognitive difficulties. Because this patient is intubated and on mechanical ventilation, the nurse cannot apply the MMSE-2; the patient is unable to perform adequately. Besides, assessing for dementia is not a prophylactic measure. Sedation and pain management, although often needed in the intensive care unit, can contribute to delirium. Covering the eyes of a patient in intensive care with ointment can be necessary to prevent corneal damage; however, it is likely to contribute to delirium because the patient will be unable to see clearly.

3. A definitive diagnosis of Alzheimer disease (AD) can be made by detecting or using which one of the following methods? a. Clinical observation of dementia b. Inability to speak with relevance c. Development of neurofibrillary tangles d. Computed axial tomographic (CAT) scan

ANS: C Confirming the development of neurofibrillary tangles is the only accurate method for diagnosing AD. Patients with AD can be observed for dementia and delirium, but these indicators are nonspecific for the disease. The inability to speak with relevance is a feature of dementia; if other causes of dementia are ruled out, then it may be dementia of the Alzheimer type. A CAT scan is the most useful means for diagnosing a stroke.

3. The community health nurse is preparing for an educational session on AD for a group of seniors. Which modifiable risk factors should the nurse include? (Select all that apply.) a. Family history c. Smoking b. Sex d. Obesity

ANS: C, D Smoking cessation and obesity are both modifiable risk factors. The focus of research on AD is on the interaction between risk-factor genes and lifestyle or environmental factors. Increasing evidence strongly points to the potential risk roles of vascular risk factors (VRFs) and disorders (e.g., midlife obesity, dyslipidemia, hypertension, cigarette smoking, obstructive sleep apnea, diabetes, cerebrovascular lesions) and the potential protective roles of psychosocial factors (e.g., higher education, regular exercise, healthy diet, intellectually challenging leisure activities, socially active and integrated lifestyle) in the pathogenesis and clinical manifestations of dementia (especially AD and vascular cognitive impairment). Family history and sex are not modifiable.

6. Which of the following approaches to hygienic care is beneficial for a patient with dementia? a. Schedule the patient's full shower at 7 AM, three mornings every week. b. Have a team give the bath with each member washing a different body area. c. Wash the perineal region first to remove potentially infectious material. d. Explain each step as you go, and keep the patient covered as much as possible while bathing.

ANS: D A person with dementia can interpret undressing for bathing as an assault. It should be performed in a way that minimizes the intrusive and exposing aspects and maintains trust between the person and only one caregiver. From the point of view of the well-being of the patient, bathing is rarely an emergency that it must be performed at a time when the patient is not receptive. Stimulation should be kept simple and focused, and alarming the patient should be avoided. The most sensitive and intimate areas should be washed last, after trust has been established between the patient and the nurse, which may have to be done anew at every encounter. From an infection-control standpoint, washing occurs from clean to dirty areas.

1. Which of the following statements is true about cognitive impairments in older adults? a. Loss or interruption of sleep can lead to delirium. b. Confusion is a normal and unavoidable consequence of aging. c. Older patients who are agitated often have a lower cognitive status than those who are quietly sitting. d. The Mini-Mental State Examination-2nd edition (MMSE-2) should be administered on admission to detect delirium.

ANS: D The MMSE-2 or a similar instrument should be administered to a patient at admission to ascertain the patient's baseline cognitive status. The loss or interruption of sleep, in of itself, does not often lead to delirium. It can potentiate delirium in the presence of other factors. Confusion or delirium is not a normal consequence of aging but an indicator of a potentially underlying problem. The hypoactive subtype of delirium can be associated with a worse prognosis than with the hyperactive subtype; it is easily overlooked.

7. A man who is 60 years of age and lives in the British Isles develops dementia. Which qualities of dementia does the nurse assess to prevent patient injury related to the type of dementia this man most likely has? a. Visual hallucinations c. Visuospatial problems b. Unilateral tremors d. Clumsy movements

ANS: D The nurse assesses the patient for failing memory and incoordination, which are characteristic of Creutzfeldt-Jakob disease (CJD) or bovine spongiform encephalopathy (also known as mad cow disease). This type of dementia began appearing in adults living in the British Isles who reported eating beef from local breeders. The nurse assesses for these qualities because the age of onset is usually around 60 years. This form of dementia progresses rapidly to death; therefore the nurse anticipates that this man will rapidly deteriorate and must be prepared to anticipate changes in motor activities and memory to maintain his safety and to prevent injury. Visual hallucinations are characteristic of Lewy body dementia. Visuospatial problems are characteristic of Parkinson disease dementia. Visuospatial problems are characteristic of frontotemporal lobe dementia.