Delirium and Dementia Disorders

The nurse is providing education to a client and family regarding complementary therapies that may be useful in the treatment for Alzheimer disease​ (AD). Which response by the family indicates the need for further​ education?

"Huperzine A is an antioxidant that supports brain function." The statement regarding Huperzine A would require additional teaching from the nurse as this is not an​ antioxidant, but a Chinese medicine that acts as an acetylcholinesterase inhibitor. All other statements are accurate and indicate appropriate understanding of the teaching presented by the nurse.

The nurse is providing home care instruction for a client recently diagnosed with Alzheimer disease​ (AD). Which statement by the client indicates the need for further​ instruction?

"I will restrict my fluid intake because it is known to cause symptoms to worsen." The client would need further education by stating that he would need to restrict fluid intake. All other statements indicate appropriate understanding of the teaching provided.

Family members are questioning a nurse about their​ mother's postoperative confusion. They​ ask, "Is our mother developing dementia from the​ anesthesia? She was thinking so clearly before the​ surgery." Which response by the nurse is the most appropriate to the​ family?

"Your mother is experiencing postanesthesia​ delirium, which should clear as soon as she is completely recovered from the​ anesthesia."

The nurse is orienting a novice nurse to the intensive care unit​ (ICU). When assessing​ clients, which items might contribute to the development of​ delirium?

A client is admitted after a motor vehicle crash with a blood alcohol level of​ 0.25%. A client is awakened for frequent assessments and treatment. A client experiences unrelieved pain.

Which is the best description of Alzheimer​ disease?

A progressive deterioration of brain function Alzheimer disease is a type of dementia that causes progressive deterioration of brain function. Delirium is a temporary state of mental confusion and fluctuating consciousness. Dystonia describes dyskinetic movements caused by disordered tonicity of muscle. Euphoria is an exaggerated feeling of physical and mental​ well-being.

Which medication is used to treat clients with​ dementia?

Acetylcholine precursors Medications to treat dementia include acetylcholine​ precursors, cholinergic​ agonists, and cholinesterase​ inhibitors, such as donepezil​ (Aricept), rivastigmine​ (Exelon), and galantamine​ (Reminyl).

The nurse is conducting an admission assessment for a client who is diagnosed with delirium of unknown cause. Which item will the nurse include during the health history of this client to determine a cause for the​ diagnosis?

Asking about drug and alcohol use The nurse would ask about a history of drug and alcohol use during the health history portion of the nursing assessment. The nurse would assess​ orientation, determine visual​ impairments, and conduct a mental status exam during the physical examination portion of the nursing assessment.

Mr.​ Casales, a​ 77-year-old man with a history of Alzheimer disease​ (AD), is brought to his healthcare provider by his daughter. She expresses concerns that her​ father's AD seems to be getting worse. Mr.​ Casales's medical record reflects that during his last healthcare​ visit, he was diagnosed as having stage 4 AD. For which changes would you assess Mr. Casales to help determine if his AD has progressed to the next​ stage?

Confusion regarding place and time Confusion regarding place and time is a manifestation of stage 5 AD and would be an indication that Mr.​ Casales's AD has progressed. An inability to remember names when introduced to new people is a sign of stage 3 AD. A knowledge deficit of recent events is a manifestation of stage 4 AD. Losing everyday objects such as keys and glasses is a sign of stage 2 AD.

A nurse is providing information about tacrine hydrochloride for the spouse of a client diagnosed with Alzheimer disease​ (AD). Which items will the nurse include in the teaching​ session?

Do not stop the medication without consulting the healthcare provider. Notify the healthcare provider if manifestations worsen. Observe the client for improvement in manifestations. The medication must be administered 1 hour before meals. Appropriate teaching points to include are not to stop the medication without consulting with the healthcare​ provider, observing for​ improvement, notifying the healthcare provider if conditions​ worsen, and that the medication must be administered 1 hour before a meal. The nurse would not include the teaching point that the medication will stop the progression of AD.

A nurse in a​ long-term care facility is providing care for a client who is receiving memantine for Alzheimer disease​ (AD). Which adverse reaction to the medication would the nurse report to the healthcare​ provider?

Guaiac positive stool Memantine is associated with gastrointestinal bleeding. Blood in the stool would require notification to the healthcare provider. The nurse would report​ bradycardia, not​ tachycardia; hypertension and not​ hypotension; weight​ loss, not weight gain.

Which are potential precipitating factors associated with​ delirium?

Infection History of falls Fracture or trauma Precipitating factors for developing delirium include​ infection, a fracture or​ trauma, and a history of falls. Excessive sleep and moderate alcohol use are not precipitating factors for delirium.

The nurse is providing care to a client who is diagnosed with delirium. Which assessment finding supports the client​'s ​diagnosis?

Lack of ability to remember childhood anecdotes Symptoms of delirium include loss of both​ short-term and​ long-term memory. Clients will also have impaired concentration and slow performance of tasks or wandering attention. Their sleep pattern is typically Insomnia at night and drowsiness during the day. They have little or no insight as to the cause of their current condition.

Which data are used to diagnose Alzheimer disease​ (AD)?

Mental status examination Presence of dementia The presence of​ dementia, a mental status​ examination, and the Alzheimer Disease Assessment Scale are used to diagnose AD. The Borg scale is used to measure perceived exertion during exercise. The​ SF-36 health​ survey, a measure of health status and quality of​ life, is not used to diagnose AD. The Braden scale is used to assess the risk for developing a pressure ulcer.

A nurse on the​ medical-surgical unit has identified safety as a priority problem for a client who is in the late stages of Alzheimer disease​ (AD). The client is awake at night and tends to wander. Which priority interventions would the nurse use in the care of this​ client?

Place nonskid slippers on the client. Keep the client​'s room free of clutter. Keep a nightlight on in the room. Take the client to the bathroom every 2 hours. Appropriate nursing interventions for this client to enhance safety include placing nonskid​ slippers, keeping the client​'s room free from​ clutter, placing a nightlight in the client​'s ​room, and taking the client to the bathroom every 2 hours. Restraints are a last resort and should not be used unless absolutely necessary.

The nurse is conducting an assessment for a client diagnosed with delirium. Which risk factor found in the client​'s health history may have caused the current​ diagnosis?

Recent heroin use The client​'s delirium may be caused by withdrawal from heroin. A history of hypertension and anorexia nervosa are not risk factors for delirium. A diet high in folic acid is a preventive measure to decrease the risk for dementia. This diet is not a risk factor for delirium.

Which are expected outcomes for clients with​ delirium?

Remain free of injury. Return to an optimal level of​ functioning, if possible Maintain adequate nutrition. One expected outcome for delirium is that the client will return to the level of functioning that​ he/she had before the onset of the delirium. The client should remain free of injury and maintain adequate nutrition. Verbalizing feelings of being able to cope with the disease and preparing advanced future planning for progressive disease stages are expected outcomes for clients with Alzheimer​ disease, who are not expected to return to an optimal level of functioning.

The nurse is planning care for a client who is diagnosed with delirium. Which cognitive intervention is appropriate for this​ client?

Reorienting to time and place While all of these interventions are appropriate for a client who is diagnosed with​ delirium, the only cognitive intervention that is listed is reorienting to time and place.

Which expected outcome is not appropriate for a client diagnosed with Alzheimer disease​ (AD)?

Restores previous level of functioning. AD is a chronic progressive disease. The client will never return to previous level of functioning. The expected outcomes for clients with AD are that the clients will remain free of​ injury; maintain an adequate balance of activity and​ rest; maintain adequate​ nutrition; maintain an adequate fluid and electrolyte​ balance; and maintain an optimal level of​ functioning, if possible.

Which medication would the nurse administer with food for a client who is diagnosed with Alzheimer disease​ (AD)?

Rivastigmine tartrate​ (Exelon) The medication that the nurse would administer with food is rivastigmine tartrate​ (Exelon). Tacrine hydrochloride​ (Cognex) should be administered one hour before a meal. Donepezil hydrocholoride​ (Aricept) is administered at bedtime. There are no specific guidelines for administering memantine​ (Namenda) with food.

Which teaching point is appropriate for the client who is not oriented to time or​ place?

The use of clocks and calendars While all of these teaching points are appropriate for clients diagnosed with dementia or Alzheimer​ disease, the only teaching point that addresses orientation of time or place is the use of clocks and calendars.

A nurse educator is preparing a presentation for a group of students regarding Alzheimer disease​ (AD). Which statement regarding the early pathophysiological changes that occur with this disease process indicates appropriate understanding by the students who attended the​ presentation?

There are deposits of insoluble material in the memory and cognition areas of the brain early in the disease.

The nurse is caring for a client with Alzheimer disease​ (AD). Which assessment findings does the nurse expect while caring for this​ client?

Trouble finding the right name for an object Gradual behavior changes if the nurse was to care for this patient over a course of time. The nurse would expect this client to have trouble finding the right name for an object and gradual behavioral changes. Confusion occurs over​ weeks, months or​ years, not over a few hours. Tachycardia and hypotension are not expected assessment findings for a client with AD.

A nurse is providing care for a client who is suspected to have Alzheimer disease​ (AD). The client has numerous tests scheduled. The client asks the nurse why there are so many tests ordered. Which response by the nurse is the most​ appropriate?

​"Alzheimer disease is diagnosed in part by ruling out other diseases that affect​ memory." AD cannot be definitively diagnosed without examining a piece of brain tissue. This is done at autopsy. AD is diagnosed by excluding other disorders. There are screening tools that identify cognition​ issues, but do not necessarily diagnose AD. The other statements are not appropriate or accurate.

Ms. Gray is a​ 42-year-old client who presents to her healthcare provider for a routine physical examination. While you are collecting Ms.​ Gray's history, she tells you that her elderly mother has just been diagnosed with Alzheimer disease​ (AD). Which statement would you make to Ms. Gray when she asks you what she can do to help protect herself from the​ disease?

​"Avoid heavy cigarette smoking and alcohol​ consumption." Although the exact cause of AD is​ unknown, heavy smoking and alcohol consumption are risk factors associated with it. Although there may be a genetic component to​ AD, individuals may be able to help prevent it by adopting a healthy lifestyle. Although there are many health benefits to maintaining glucose control and a healthy​ weight, obesity and hyperglycemia have not been shown to be risk factors for AD. Vitamin E and​ omega-3 fatty acids help reduce oxidative​ stress, which has been found to be a risk factor for AD.

The nurse is conducting an admission assessment for a client diagnosed with late stage Alzheimer disease​ (AD). Which statement by the client​'s spouse indicates a need for further teaching regarding the progression of the​ disease?

​"I feel tired all the time. And I often feel guilty and angry. I​ don't understand it. My own health really needs to be secondary. I need to better organize my time so that I can get everything done each​ day."

You are caring for Mr.​ Mitchell, a​ 74-year-old client who is diagnosed with delirium after having an emergency appendectomy 2 days ago. Mrs.​ Mitchell, the​ client's wife, asks the nurse how this could have happened. Based on the assessment data​ collected, which response is most​ appropriate?

​"This can happen with opioids that have been administered to control your​ husband's pain." Opioid use is a risk factor for developing delirium. This response is most appropriate response to Mrs.​ Mitchell's question. Delirium is not a normal part of aging. Heavy smoking and hypertension are not risk factors for​ delirium: they are risk factors for dementia and Alzheimer disease.

Mrs. Matsuoka is a​ 68-year-old woman who was brought to her healthcare provider by her husband after he noticed that she was frequently forgetting familiar names and misplacing her keys. After an extensive​ examination, the healthcare provider diagnoses Mrs. Matsuoka with Alzheimer disease​ (AD). Mrs. Matsuoka asks you if there are any complementary therapies that she can use to help slow down the progression of her disease. Which reply would you provide to Mrs.​ Matsuoka?

​"Zinc supplements are believed to support brain​ function." Zinc supplements are believed to support brain function for clients with AD. Although coenzyme Q10 is naturally occurring antioxidant believed to support brain​ function, it does not act as an acetylcholinesterase inhibitor. Although Huperzine A is believed to act as an acetylcholinesterase inhibitor and can help with the manifestations of​ AD, it has not been found to reverse the brain damage that occurs with AD. St.​ John's wort improves mood and decreases anxiety and insomnia related to depression. It is not commonly used for AD.