Cognitive impairments, Delirium, Demenita, Alzheimers-NCLCEX
The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which of the following behaviors? 1. Sleep disturbances. 2. Concomitant depression. 3. Agitation and assaultiveness. 4. Confusion and withdrawal.
3. Antipsychotics are most effective with agitation and assaultiveness. Antipsychotics have little effect on sleep disturbances, concomitant depression, or confusion and withdrawal.
When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate? 1. Cancer of any kind. 2. Impaired hearing. 3. Prescription drug intoxication. 4. Heart failure.
3. Polypharmacy is much more common in the elderly. Drug interactions increase the incidence of intoxication from prescribed medications, especially with combinations of analgesics, digoxin, diuretics, and anticholinergics. With drug intoxication, the onset of the delirium typically is quick. Although cancer, impaired hearing, and heart failure could lead to delirium in the elderly, the onset would be more gradual.
When developing the plan of care for a client with Alzheimer's disease who is experiencing moderate impairment, which of the following types of care should the nurse expect to include? 1. Prompting and guiding activities of daily living. 2. Managing a medication schedule. 3. Constant supervision and total care. 4. Supervision of risky activities such as shaving.
1. Considerable assistance is associated with moderate impairment when the client cannot make decisions but can follow directions. Managing medications is needed even in mild impairment. Constant care is needed in the terminal phase, when the client cannot follow directions. Supervision of shaving is appropriate with mild impairment— that is, when the client still has motor function but lacks judgment about safety issues.
In planning for the discharge of a client with a cognitive disorder, it is important to assess the client's caregiver support system. Which aspects are the most crucial to assess? Select all that apply. 1. Availability of resources for caregiver support. 2. Ability to provide the level of care and supervision needed by the client. 3. Willingness to transport the client to medical and psychiatric services. 4. Interest in engaging the cognitively disordered family member in reminiscence and games. 5. Willingness to install door alarms and make other safety changes. 6. Understanding the client's abilities and limitations.
1, 2, 3, 5, 6. It is important for a caregiver to have support for herself as well as be able to provide adequate safety, supervision, and medical care to the client. The caregiver must also have realistic expectations of the client, given his abilities and limitations. Reminiscing and engaging the client in games is desirable but not crucial to care.
When communicating with the client who is experiencing dementia and exhibiting decreased attention and increased confusion, which of the following interventions should the nurse employ as the first step? 1. Using gentle touch to convey empathy. 2. Rephrasing questions the client doesn't understand. 3. Eliminating distracting stimuli such as turning off the television. 4. Asking the client to go for a walk while talking.
3. Competing and excessive stimuli lead to sensory overload and confusion. Therefore, the nurse should first eliminate any distracting stimuli. After this is accomplished, then using touch and rephrasing questions are appropriate. Going for a walk while talking has little benefit on attention and confusion.
Nursing staff are trying to provide for the safety of an elderly female client with moderate dementia. She is wandering at night and has trouble keeping her balance. She has fallen twice but has had no resulting injuries. The nurse should: 1. Move the client to a room near the nurse's station and install a bed alarm. 2. Have the client sleep in a reclining chair across from the nurse's station. 3. Help the client to bed and raise all four bedrails. 4. Ask a family member to stay with the client at night.
1. Using a bed alarm enables the staff to respond immediately if the client tries to get out of bed. Sleeping in a chair at the nurse's station interferes with the client's restful sleep and privacy. Using all four bedrails is considered a restraint and unsafe practice. It is not appropriate to expect a family member to stay all night with the client.
The husband of a client with Alzheimer's disease that was diagnosed 6 years ago approaches the nurse and says, "I'm so excited that my wife is starting to use donepezil (Aricept) for her illness." The nurse should tell the husband: 1. The medication is effective mostly in the early stages of the illness. 2. The adverse effects of the drug are numerous. 3. The client will attain a functional level of that of 6 years ago. 4. Effectiveness in the terminal phase of the illness is scientifically proven.
1. When compared with other similar medications, donepezil (Aricept) has fewer adverse effects. Donepezil is effective primarily in the early stages of the disease. The drug helps to slow the progression of the disease if started in the early stages. After the client has been diagnosed for 6 years, improvement to the level seen 6 years ago is highly unlikely. Data are not available to support the drug's effectiveness for clients in the terminal phase of the disease.
A client with early dementia exhibits disturbances in her mental awareness and orientation to reality. The nurse should expect to assess a loss of ability in which of the following other areas? 1. Speech. 2. Judgment. 3. Endurance. 4. Balance.
2. Clients with chronic cognitive disorders experience defects in memory orientation and intellectual functions, such as judgment and discrimination. Loss of other abilities, such as speech, endurance, and balance, is less typical.
A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following? 1. Administer PRN haloperidol (Haldol) to decrease the need to walk. 2. Assess the client's gait for steadiness. 3. Restrain the client in a geriatric chair. 4. Administer PRN lorazepam (Ativan) to provide sedation.
2. Elderly clients have increased risk for falls due to balance problems, medication use, and decreased eyesight. Haldol may cause extrapyramidal side effects (EPSE) which increase the risk for falls. The client is not agitated, so restraints are not indicated. Ativan may increase fall risk and cause paradoxical excitement.
The term motor apraxia relates to a decline in motor patterns essential for complex motor tasks. However, the client with severe dementia may be able to perform which of the following actions? 1. Balance a checkbook accurately. 2. Brush the teeth when handed a toothbrush. 3. Use confabulation when telling a story. 4. Find misplaced car keys.
2. Highly conditioned motor skills, such as brushing the teeth, may be retained by the client who has dementia and motor apraxia. Balancing a checkbook involves calculations, a complex skill that is lost with severe dementia Confabulation is fabrication of details to fill a memory gap. This is more common when the client is aware of a memory problem, not when dementia is severe. Finding keys is a memory factor, not a motor function.
The nurse observes a client in a group who is reminiscing about his past. Which effect should the nurse expect reminiscing to have on the client's functioning in the hospital? 1. Increase the client's confusion and disorientation. 2. Cause the client to become sad. 3. Decrease the client's feelings of isolation and loneliness. 4. Keep the client from participating in therapeutic activities.
3. Reminiscing can help reduce depression in an elderly client and lessens feelings of isolation and loneliness. Reminiscing encourages a focus on positive memories and accomplishments as well as shared memories with other clients. An increase in confusion and disorientation is most likely the result of other cognitive and situational factors, such as loss of short-term memory, not reminiscing. The client will not likely become sad because reminiscing helps the client connect with positive memories. Keeping the client from participating in therapeutic activities is less likely with reminiscing.
The nurse discusses the possibility of a client's attending day treatment for clients with early Alzheimer's disease. Which of the following is the best rationale for encouraging day treatment? 1. The client would have more structure to his day. 2. Staff are excellent in the treatment they offer clients. 3. The client would benefit from increased social interaction. 4. The family would have more time to engage in their daily activities.
3. The best rationale for day treatment for the client with Alzheimer's disease is the enhancement of social interactions. More daily structure, excellent staff, and allowing caregivers more time for themselves are all positive aspects, but they are less focused on the client's needs.
The client with Alzheimer's disease may have delusions about being harmed by staff and others. When the client expresses fear of being killed by staff, which of the following responses is most appropriate? 1. "What makes you think we want to kill you?" 2. "We like you too much to want to kill you." 3. "You are in the hospital. We are nurses trying to help you." 4. "Oh, don't be so silly. No one wants to kill you here."
3. The nurse needs to present reality without arguing with the delusions. Therefore, stating that the client is in the hospital and the nurses are trying to help is most appropriate. The client doesn't recognize the delusion or why it exists. Telling the client that the staff likes him too much to want to kill him is inappropriate because the client believes the delusions and doesn't know that they are false beliefs. It also restates the word, kill, which may reinforce the client's delusions. Telling the client not to be silly is condescending and disparaging and therefore inappropriate.
The nurse is attempting to draw blood from a woman with a diagnosis of delirium who was admitted last evening. The client yells out, "Stop; leave me alone. What are you trying to do to me? What's happening to me?" Which response by the nurse is most appropriate? 1. "The tests of your blood will help us figure out what is happening to you." 2. "Please hold still so I don't have to stick you a second time." 3. "After I get your blood, I'll get some medicine to help you calm down." 4. "I'll tell you everything after I get your blood tests to the laboratory."
1. Explaining why blood is being taken responds to the client's concerns or fears about what is happening to her. Threatening more pain or promising to explain later ignores or postpones meeting the client's need for information. The client's statements do not reflect loss of self control requiring medication intervention.
The client in the early stage of Alzheimer's disease and his adult son attend an appointment at the community mental health center. While conversing with the nurse, the son states, "I'm tired of hearing about how things were 30 years ago. Why does Dad always talk about the past?" The nurse should tell the son: 1. "Your dad lost his short-term memory, but he still has his long-term memory." 2. "You need to be more accepting of your dad's behavior." 3. "I want you to understand your dad's level of anxiety." 4. "Telling your dad that you are tired of hearing about the past will help him stop."
1. The son's statements regarding his father's recalling past events is typical for family members of clients in the early stage of Alzheimer's disease, when recent memory is impaired. Telling the son to be more accepting is critical and not an attempt to educate. Understanding the client's level of anxiety is unrelated to the memory loss of Alzheimer's disease. The client cannot stop reminiscing at will.
Which of the following is essential when caring for a client who is experiencing delirium? 1. Controlling behavioral symptoms with low-dose psychotropics. 2. Identifying the underlying causative condition or illness. 3. Manipulating the environment to increase orientation. 4. Decreasing or discontinuing all previously prescribed medications.
2. The most critical aspect when caring for the client with delirium is to institute measures to correct the underlying causative condition or illness. Controlling behavioral symptoms with low-dose psychotropics, manipulating the environment, and decreasing or discontinuing all medications may be dangerous to the client's health.
When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant? 1. Allow the client to go to bed four to five times during the day. 2. Test the cognitive functioning of the client several times a day. 3. Provide reality orientation even if the memory loss is severe. 4. Maintain consistency in environment, routine, and caregivers.
4. Change increases stress. Therefore, the most important and relevant suggestion is to maintain consistency in the client's environment, routine, and caregivers. Although rest periods are important, going to bed interferes with the sleep-wake cycle. Rest in a recliner chair is more useful. Testing cognitive functioning and reality orientation are not likely to be successful and may increase stress if memory loss is severe.
The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the health care provider? 1. Paradoxical excitement. 2. Headache. 3. Slowing of reflexes. 4. Fatigue.
1. Although all of the side effects listed are possible with Ativan, paradoxical excitement is cause for immediate discontinuation of the medication. (Paradoxical excitement is the opposite reaction to Ativan than is expected.) The other side effects tend to be minor and usually are transient.
Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium? 1. Explain the experience of having delirium. 2. Resume a normal sleep-wake cycle. 3. Regain orientation to time and place. 4. Establish normal bowel and bladder function.
3. In approximately 2 to 3 days, the client should be able to regain orientation and thus become oriented to time and place. Being able to explain the experience of having delirium is something that the client is expected to achieve later in the course of the illness, but ultimately before discharge. Resuming a normal sleep-wake cycle and establishing normal bowel and bladder function probably will take longer, depending on how long it takes to resolve the underlying condition.
An 83-year-old woman is admitted to the unit after being examined in the emergency department (ED) and diagnosed with delirium. After the admission interviews with the client and her grandson, the nurse explains that there will be more laboratory tests and X-rays done that day. The grandson says, "She has already been stuck several times and had a brain scan or something. Just give her some medicine and let her rest." The nurse should tell the grandson which of the following? Select all that apply. 1. "I agree she needs to rest, but there is no one specific medicine for your grandmother's condition." 2. "The doctor will look at the results of those tests in the ED and decide what other tests are needed." 3. "Delirium commonly results from underlying medical causes that we need to identify and correct." 4. "Tell me about your grandmother's behaviors and maybe I could figure out what medicine she needs." 5. "I'll ask the doctor to postpone more tests until tomorrow."
1, 2, 3. The client does need rest and it is true that there is no specific medicine for delirium, but it is crucial to identify and treat the underlying causes of delirium. Other tests will be based on the results of already completed tests. Although some medications may be prescribed to help the client with her behaviors, this is not the primary basis for medication orders. Because the underlying medical causes of delirium could be fatal, treatment must be initiated as soon as possible. It is not the nurse's role to determine medications for this client. Postponing tests until the next day is inappropriate.
A client has been in the critical care unit for 3 days following a severe myocardial infarction. Although he is medically stable, he has begun to have fluctuating episodes of consciousness, illogical thinking, and anxiety. He is picking at the air to "catch these baby angels flying around my head." While waiting for medical and psychiatric consults, the nurse must intervene with the client's needs. Which of the following needs have the highest priority? Select all that apply. 1. Decreasing as much "foreign" stimuli as possible. 2. Avoiding challenging the client's perceptions about "baby angels." 3. Orienting the client about his medical condition. 4. Gently presenting reality as needed. 5. Calling the client's family to report his onset of dementia.
1, 2, 4. The abnormal stimuli of the critical care unit can aggravate the symptoms of delirium. Arguing with hallucinations is inappropriate. When a client has illogical thinking, gently presenting reality is appropriate. Dementia is not the likely cause of the client's symptoms. The client is experiencing delirium, not dementia.
The client with dementia states to the nurse, "I know you. You're Margaret, the girl who lives down the street from me." Which of the following responses by the nurse is most therapeutic? 1. "Mrs. Jones, I'm Rachel, a nurse here at the hospital." 2. "Now Mrs. Jones, you know who I am." 3. "Mrs. Jones, I told you already, I'm Rachel and I don't live down the street." 4. "I think you forgot that I'm Rachel, Mrs. Jones."
1. Because of the client's short-term memory impairment, the nurse gently corrects the client by stating her name and who she is. This approach decreases anxiety, embarrassment, and shame and maintains the client's self-esteem. Telling the client that she knows who the nurse is or that she forgot can elicit feelings of embarrassment and shame. Saying, "I told you already" sounds condescending, as if blaming the client for not remembering.
In addition to developing over a period of hours or days, the nurse should assess delirium as distinguishable by which of the following characteristics? 1. Disturbances in cognition and consciousness that fluctuate during the day. 2. The failure to identify objects despite intact sensory functions. 3. Significant impairment in social or occupational functioning over time. 4. Memory impairment to the degree of being called amnesia.
1. Fluctuating symptoms are characteristic of delirium. The failure to identify objects despite intact sensory functions, significant impairment in social or occupational functioning over time, and memory impairment to the degree
Which of the following should the nurse expect to include as a priority in the plan of care for a client with delirium based on the nurse's understanding about the disturbances in orientation associated with this disorder? 1. Identifying self and making sure that the nurse has the client's attention. 2. Eliminating the client's napping in the daytime as much as possible. 3. Engaging the client in reminiscing with relatives or visitors. 4. Avoiding arguing with a suspicious client about his perceptions of reality.
1. Identifying oneself and making sure that the nurse has the client's attention addresses the difficulties with focusing, orientation, and maintaining attention. Eliminating daytime napping is unrealistic until the cause of the delirium is determined and the client's ability to focus and maintain attention improves. Engaging the client in reminiscing and avoiding arguing are also unrealistic at this time.
When helping the families of clients with Alzheimer's disease cope with vulgar or sexual behaviors, which of the following suggestions is most helpful? 1. Ignore the behaviors, but try to identify the underlying need for the behaviors. 2. Give feedback on the inappropriateness of the behaviors. 3. Employ anger management strategies. 4. Administer the prescribed risperidone (Risperdal).
1. The vulgar or sexual behaviors are commonly expressions of anger or more sensual needs that can be addressed directly. Therefore, the families should be encouraged to ignore the behaviors but attempt to identify their purpose. Then the purpose can be addressed, possibly leading to a decrease in the behaviors. Because of impaired cognitive function, the client is not likely to be able to process the inappropriateness of the behaviors if given feedback. Likewise, anger management strategies would be ineffective because the client would probably be unable to process the inappropriateness of the behaviors. Risperidone (Risperdal) may decrease agitation, but it does not improve social behaviors.
During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply. 1. Ask the client's physician for a strong sleep medicine. 2. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. 3. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day. 4. Promote relaxation before bedtime with a warm bath or relaxing music. 5. Have the daughter encourage the use of caffeinated beverages during the day to keep her mother awake.
2, 3, 4. A set routine and brief exercises help decrease daytime sleeping. Decreasing caffeine and fluids and promoting relaxation at bedtime promote nighttime sleeping. A strong sleep medicine for an elderly client is contraindicated due to changes in metabolism, increased adverse effects, and the risk of falls. Using caffeinated beverages may stimulate metabolism but can also have long-lasting adverse effects and may prevent sleep at bedtime.
The family of a client, diagnosed with Alzheimer's disease, wants to keep the client at home. They say that they have the most difficulty in managing his wandering. The nurse should instruct the family to do which of the following? (Select all that apply). 1. Ask the physician for a sleeping medication. 2. Install motion and sound detectors. 3. Have a relative sit with the client all night. 4. Have the client wear a Medical Alert bracelet. 5. Install door alarms and high door locks.
2, 4, 5. Motion and sound detectors, a Medical Alert bracelet, and door alarms are all appropriate interventions for wandering. Sleep medications do not prevent wandering before and after the client is asleep and may have negative effects. Having a relative sit with the client is usually an unrealistic burden.
Which of the following is a priority to include in the plan of care for a client with Alzheimer's disease who is experiencing difficulty processing and completing complex tasks? 1. Repeating the directions until the client follows them. 2. Asking the client to do one step of the task at a time. 3. Demonstrating for the client how to do the task. 4. Maintaining routine and structure for the client.
2. Because the client is experiencing difficulty processing and completing complex tasks, the priority is to provide the client with only one step at a time, thereby breaking the task up into simple steps, ones that the client can process. Repeating the directions until the client follows them or demonstrating how to do the task is still too overwhelming to the client because of the multiple steps involved. Although maintaining structure and routine is important, it is unrelated to task completion.
A 69-year-old client is admitted and diagnosed with delirium. Later in the day, he tries to get out of the locked unit. He yells, "Unlock this door. I've got to go see my doctor. I just can't miss my monthly Friday appointment." Which of the following responses by the nurse is most appropriate? 1. "Please come away from the door. I'll show you your room." 2. "It's Tuesday and you are in the hospital. I'm Anne, a nurse." 3. "The door is locked to keep you from getting lost." 4. "I want you to come eat your lunch before you go the doctor."
2. Loss of orientation, especially for time and place, is common in delirium. The nurse should orient the client by telling him the time, date, place, and who the client is with. Taking the client to his room and telling him why the door is locked does not address his disorientation. Telling the client to eat before going to the doctor reinforces his disorientation.
A nurse on the Geropsychiatric unit receives a call from the son of a recently discharged client. He reports that his father just got a prescription for memantine (Namenda) to take "on top of his donepezil (Aricept)." The son then asks, "Why does he have to take extra medicines?" The nurse should tell the son: 1. "Maybe the Aricept alone isn't improving his dementia fast enough or well enough." 2. "Namenda and Aricept are commonly used together to slow the progression of dementia." 3. "Namenda is more effective than Aricept. Your father will be tapered off the Aricept." 4. "Aricept has a short half-life and Namenda has a long half-life. They work well together."
2. The two medicines are commonly given together. Neither medicine will improve dementia, but may slow the progression. Neither medicine is more effective than the other; they act differently in the brain. Both medicines have a half-life of 60 or more hours.
While assessing a client diagnosed with dementia, the nurse notes that her husband is concerned about what he should do when she uses vulgar language with him. The nurse should: 1. Tell her that she is very rude. 2. Ignore the vulgarity and distract her. 3. Tell her to stop swearing immediately. 4. Say nothing and leave the room.
2. Vulgar language is common in clients with dementia when they are having trouble communicating about a topic. Ignoring the vulgarity and distracting her is appropriate. Telling the client she is rude or to stop swearing will have no lasting effect and may cause agitation. Just leaving the room is abandonment that the client will not understand.
A client is experiencing agnosia as a result of vascular dementia. She is staring at dinner and utensils without trying to eat. Which intervention should the nurse attempt first? 1. Pick up the fork and feed the client slowly. 2. Say, "It's time for you to start eating your dinner." 3. Hand the fork to the client and say, "Use this fork to eat your green beans." 4. Save the client's dinner until her family comes in to feed her.
3. Agnosia is the lack of recognition of objects and their purpose. The nurse should inform the client about the fork and what to do with it. Feeding the client does not address the agnosia or give the client specific directions. It should only be attempted if identifying the fork and explaining what to do with it is ineffective. Waiting for the family to care for the client is not appropriate unless identifying the fork and explaining or feeding the client are not successful.
A client with dementia who prefers to stay in his room has been brought to the dayroom. After 10 minutes, the client becomes agitated and retreats to his room again. The nurse decides to assess the conditions in the dayroom. Which is the most likely occurrence that is disturbing to this client? 1. There is only one other client in the dayroom; the rest are in a group session in another room. 2. There are three staff members and one physician in the nurse's station working on charting. 3. A relaxation tape is playing in one corner of the room, and a television airing a special on crime is playing in the opposite corner. 4. A housekeeping staff member is washing off the countertops in the kitchen, which is on the far side of the dayroom.
3. The tape and television are competing, even conflicting, stimuli. Crime events portrayed on television could be misperceived as a real threat to the client. A low number of clients and the presence of a few staff members quietly working are less intense stimuli for the client and not likely to be disturbing.
An elderly woman's husband died. When her brother arrives for the funeral, he notices her short-term memory problems and occasional disorientation. A few weeks later, she calls him to say that her husband just died. She says, "I didn't know he was so sick. Why did he die now?" She also complains of not sleeping, urinary frequency and burning, and seeing rats in the kitchen. A home care nurse is sent to evaluate her situation and finds the woman reclusive and passive, but pleasant. The nurse calls the woman's primary care physician to discuss the client's situation and background, and give his assessment and recommendations. The nurse concludes that the woman: 1. Is experiencing the onset of Alzheimer's disease. 2. Is having trouble adjusting to living alone without her husband. 3. Is having delayed grieving related to her Alzheimer's disease. 4. Is experiencing delirium and a urinary tract infection.
4. Delirium is commonly due to a medical condition such as a UTI in the elderly. Delirium often involves memory problems, disorientation, and hallucinations. It develops rather quickly. There is not enough data to suggest Alzheimer's disease especially given the quick onset of symptoms. Delayed grieving and adjusting to being alone are unlikely to cause hallucinations.
The son of an elderly client who has cognitive impairments approaches the nurse and says, "I'm so upset. The physician says I have 4 days to decide on where my dad is going to live." The nurse responds to the son's concerns, gives him a list of types of living arrangements, and discusses the needs, abilities, and limitations of the client. The nurse should intervene further if the son makes which comment? 1. "Boy, I have a lot to think about before I see the social worker tomorrow." 2. "I think I can handle most of Dad's needs with the help of some home health care." 3. "I'm so afraid of making the wrong decision, but I can move him later if I need to." 4. "I want the social worker to make this decision so Dad won't blame me."
4. Expecting the social worker to make the decision indicates that the son is avoiding participating in decisions about his father. The other responses convey that the son understands the importance of a careful decision, the availability of resources, and the ability to make new plans if needed.
While educating the daughter of a client with dementia about the illness, the daughter complains to the nurse that her mother distorts things. The nurse understands that the daughter needs further teaching about dementia when she makes which statement? 1. "I tell her reality, such as, 'That noise is the wind in the trees.'" 2. "I understand the misperceptions are part of the disease." 3. "I turn off the radio when we're in another room." 4. "I tell her she is wrong and then I tell her what's right."
4. Telling the client that she is wrong and then telling her what is right is argumentative and challenging. Arguing with or challenging distortions is least effective because it increases defensiveness. Telling the client about reality indicates awareness of the issues and is appropriate. Acknowledging that misperceptions are part of the disease indicates an understanding of the disease and an awareness of the issues. Turning off the radio helps to limit environmental stimuli and indicates an awareness of the issues.
A 90-year-old client diagnosed with major depression is suddenly experiencing sleep disturbances, inability to focus, poor recent memory, altered perceptions, and disorientation to time and place. Lab results indicate the client has a urinary tract infection and dehydration. After explaining the situation and giving the background and assessment data, the nurse should make which of the following recommendations to the client's physician? 1. An order to place the client in restraints. 2. A reevaluation of the client's mental status. 3. The transfer of the client to a medical unit. 4. A transfer of the client to a nursing home.
4. The client is showing symptoms of delirium, a common outcome of UTI in older adults. The nurse can request a transfer to a medical unit for acute medical intervention. The client's symptoms are not just due to a worsening of the depression. There are not indications that the client needs restraints or a transfer to a nursing home at this point.
The nurse determines that the son of a client with Alzheimer's disease needs further education about the disease when he makes which of the following statements? 1. "I didn't realize the deterioration would be so incapacitating." 2. "The Alzheimer's support group has so much good information." 3. "I get tired of the same old stories, but I know it's important for Dad." 4. "I woke up this morning expecting that my old Dad would be back."
4. The statement about expecting that the old Dad would be back conveys a lack of acceptance of the irreversible nature of the disease. The statement about not realizing that the deterioration would be so incapacitating is based in reality. The statement about the Alzheimer's group is based in reality and demonstrates the son's involvement with managing the disease. Stating that reminiscing is important reflects a realistic interpretation on the son's part.
Transfer data for a client brought by ambulance to the hospital's psychiatric unit from a nursing home indicate that the client has become increasingly confused and disoriented. The client's behavior is found to be the result of cerebral arteriosclerosis. Which of the following behaviors of the nursing staff should positively influence the client's behavior? Select all that apply. 1. Limiting the client's choices. 2. Accepting the client as he is. 3. Allowing the client to do as he wishes. 4. Acting nonchalantly. 5. Explaining to the client what he needs to do step-by-step.
1, 2, 5. Confused clients need fewer choices, acceptance as a person, and step-by-step directions. Allowing the client to do as he wishes can lead to substandard care and the risk of harm. Acting nonchalantly conveys a lack of caring.
