PSYCHIATRIC MENTAL HEALTH (VIDEBACK) CHAPTER 24 COGNITIVE DISORDERS

A nurse is caring for a client diagnosed with delirium who has been brought for treatment by the client's adult child. While taking the client's history, which question would be most appropriate for the nurse to ask the client's adult child?

"Has your parent taken any medications recently?" Explanation: Delirium is typically caused by medications, urinary or upper respiratory tract infections, fluid and electrolyte imbalances, and metabolic disturbances. Therefore, questioning the adult child about the client's medication use would be most appropriate. Head injury or stroke may lead to changes in consciousness but not delirium. Although acute or chronic stress may be a risk factor for the development of delirium, this would not be the most appropriate question to ask at this time.

The nurse understands that numerous comorbidities can contribute to the development of dementia. Which client may be at risk for dementia?

A 49-year-old client whose human immunodeficiency virus (HIV) has progressed to acquired immunodeficiency syndrome (AIDS) Explanation: HIV/AIDS is known to cause dementia. Cancer does not normally result in dementia, and the cognitive changes that may result from a UTI or polydipsia are reversible and thus classified as delirium.

A client is diagnosed with Alzheimer's disease. While assessing the client, the nurse notes that the client has trouble identifying objects such as a key and spoon. The nurse would document this as what?

Agnosia Explanation: Deficits typically assessed in clients with Alzheimer's disease include: aphasia (alterations in language ability), apraxia (impaired ability to execute motor activities despite intact motor functioning), agnosia (failure to recognize or identify objects despite intact sensory function), or a disturbance of executive functioning (ability to think abstractly, plan, initiate, sequence, monitor, and stop complex behavior).

The spouse caregiver of a client with dementia tells the nurse that the client has been agitated lately. The spouse states, "I don't know how to handle this. The client was always such a gentle person!" Which interventions should the nurse suggest?

Distract the client with family photos and discuss the events pictured. Explanation: At times, there may seem to be no way to resolve the emotional frustration, agitation, or outbursts of the client who is angry with the environment and those in it. The caregiver might find it beneficial to redirect or distract the client. This can be done by asking to see a client's personal items, such as photographs, and then talking about the family members and life events illustrated by the photographs in the book.

A nurse is providing education to the care provider of a cognitively impaired client who is prescribed a cholinesterase inhibitor. Which information about medication side effects should the nurse be sure to include?

Gastrointestinal (GI) symptoms Explanation: All four of the commonly prescribed cholinesterase inhibitors have the possibility of producing GI symptoms

A nurse is caring for a client with delirium. The client sees a thermometer on the nurse's table and shouts, "Don't stab me!" and cowers. Which feature of delirium is this client exhibiting?

Illusion Explanation: Clients with delirium may experience illusions. In this case, the client is having an illusion that the thermometer is a knife. Euphoria refers to an extremely elated mood; however, the client does not appear to be highly elated. Hallucinations are typically things that clients "see" with no stimulus in reality. Misinterpretations are a misunderstanding of an actual event or stimulus. In many cases, the client cannot be convinced that their misinterpretation is incorrect.

The client is a 68-year-old who has been showing signs of Alzheimer's disease, including visual hallucinations and disturbed behaviors. When the client was placed on antipsychotic medications, the client suffered significant adverse reactions. This could indicate that the client does not have Alzheimer's disease, but which condition?

Lewy body dementia Explanation: Lewy body disease is sometimes mistaken for Alzheimer's disease because of clinical similarity, but it has earlier and more prominent visual hallucinations, parkinsonian features, and disturbed behaviors. A distinguishing characteristic is significant adverse reactions to antipsychotic drugs.

Which of these is a N-methyl-D-aspartic acid (NMDA) receptor antagonist?

Memantine Explanation: Memantine is a NMDA receptor antagonist that has been shown to improve cognition and activities of daily living in clients with moderate to severe symptoms of dementia. Galantamine, donepezil, and rivastigmine are cholinesterase inhibitors.

A client with dementia becomes extremely agitated shortly after being admitted to the psychiatric unit. The nurse is reluctant to use physical restraints to control the client. What is a likely reason the nurse has this reluctance?

Physical restraints may increase the client's agitation. Explanation: The use of physical restraints are usually a last resort for clients with dementia, as restraint use may increase any fears or thoughts of being threatened. The nurse may need to use physical restraints if the client is pulling at intravenous lines or catheters. Physical restraints do not commonly cause injury to the client or lead to fatality.

The client has advanced Alzheimer's disease and becomes confused at mealtimes. The client has agnosia, apraxia, and disturbed executive functioning. Which is the most appropriate nursing intervention?

Provide the client with a tray, opening containers for the client. Explanation: The ability of clients to care for themselves decreases as the severity of the cognitive order increases. Caregivers can help by enhancing the client's environment to facilitate his or her limited ability to perform activities of daily living and instrumental activities of daily living and by fulfilling unmet client needs.

The nurse is assessing a client who is diagnosed with delirium. Which presenting sign in the client indicates to the nurse that the client may may have a diagnosis of dementia?

Remote memory loss Explanation: Impaired memory may be present in both delirium and dementia. However, remote memory loss and forgetting the names of adult children, their occupations, or even their own names occurs in the later stages of dementia. Irrelevant speech, visual hallucinations, and impaired consciousness are signs of delirium. In dementia, speech is normal at the initial stages and then progresses to aphasia. Hallucinations are less common in dementia. Consciousness is usually not impaired in client with dementia.

Which can be identified as a hallmark symptom of dementia?

Short-term memory loss Explanation: As a broad diagnosis, dementia includes conditions in which short-term memory loss is a hallmark. The deterioration of memory is so great that it prevents clients from functioning at previous levels of social and occupational performance and seriously deters them from learning new information.

The nurse receives a report that a 75-year-old client is recovering from surgery. During the shift, the nurse notes that the client is forgetful and restless. Several times, the client calls the nurse the name of the client's daughter. The nurse interprets this behavior as what?

Signs of delirium Explanation: Delirium is a syndrome characterized by a rapid onset of cognitive dysfunction and disruption in consciousness. Growing rates of delirium mirror the increasing older adult population and are expected to continue to rise. Delirium is the most common psychiatric syndrome in general hospitals, occurring in up to 50% of elderly inpatients. It is associated with significantly increased morbidity and mortality both during and after hospitalization.

The client has early Alzheimer's disease. When asked about family history, the client relates that the client has two children who are both grown and who visit the client around the holidays each year. The nurse subsequently discovers that the client has one child who is currently assigned overseas and who has not been home for 2 years. Which would best describe the client's behavior?

The client is confabulating, most likely to cover for memory deficit. Explanation: The client may have some difficulty recalling events or knowledge that the client formerly knew to be fact. Because of the inability to recall recent events, the client may be confabulating, or filling in memory gaps with fabricated or imagined data.

The nurse is assessing a client with aphasia and notes the client may be exhibiting echolalia during their conversation. What signs does the nurse observe that leads to this conclusion?

The client may echo whatever is heard. Explanation: A client suffering from aphasia may exhibit echolalia, or echoing what is heard during conversation. Clients who repeat words and sounds over and over are suffering from palilalia. Difficulty forming sentences and producing vague speech that is difficult to interpret can be seen in clients with dementia.

A 65-year-old has been admitted to the intensive care unit following surgical resection of the bowel. The client has developed a fever. Which additional signs indicate the client has developed delirium?

The client removes the client's surgical bandage and begins picking at the sheets. Explanation: Features of delirium may include a reduced level of consciousness, a disrupted sleep-wake cycle, and an abnormality of psychomotor behavior. The hospitalized client with delirium will try to remove intravenous lines and other tubes, "pick" at the air or the bed sheet, and try to climb over side rails or the end of the bed.

Major goals for the nursing care of clients with dementia should include what?

The client will be safe, be physiologically stable, and have infrequent episodes of agitation. Explanation: Safety is always the nurse's first priority; clients with dementia often cannot meet their basic physical needs and agitation is a common emotional response to confusion and disorientation.

After educating a group of nurses on Alzheimer's disease and appropriate nursing care, the group leader determines that the education was successful when the nurses identify which as the foundation for providing care to the client and family?

Therapeutic relationship Explanation: A therapeutic relationship is the basis for interventions for clients with dementia and their families. Care of the client entails a long-term relationship needing much support and expert nursing care. Interventions should be delivered within the relationship context. Medication therapy, injury prevention, and promoting independent functioning within the limits of the disorder are important components of care, but the therapeutic relationship is critical.

An 82-year-old client with a diagnosis of vascular dementia has been admitted to the geriatric psychiatry unit of the hospital. In planning the care of this client, which outcome should the nurse prioritize?

he client will remain free from injury. Explanation: Control of agitation and promotion of self-worth are important outcomes, but safety is a priority concern. A client whose diagnosis necessitates hospitalization may or may not be capable of identifying or making changes in life routines.

What is the initial intervention the nurse should implement when helping a client diagnosed with dementia deal with paranoid delusions?

observe the client in order to identify the triggers for the delusions Explanation: Clients with dementia may believe that their physical safety is jeopardized; they may feel threatened or suspicious and paranoid. These feelings can lead to agitated or erratic behavior that compromises safety. Avoiding direct confrontation of the client's fears is important. Clients with dementia may struggle with fears and suspicion throughout their illness. Triggers of suspicion include strangers, changes in the daily routine, or impaired memory. The nurse must discover and address these environmental triggers rather than confront the paranoid ideas.

What is the greatest benefit support groups provide to the caregivers of clients diagnosed with dementia?

provides interaction with those with similar concerns Explanation: Attending a support group regularly also means that caregivers have time with people who understand the many demands of caring for a family member with dementia. While the other options suggest accurate results, none are the greatest benefit such a support group experience can provide.

The nurse should consider the intervention referred to as "going along with" when managing the care of which client?

the older widower who is worried about his wife not being able to visit because of the snow Explanation: Going along means providing emotional reassurance to clients without correcting their misperception or delusion. It is important to remember that different interventions are indicated for dealing with psychotic symptoms, depending on the cause. People with dementia cannot regain their cognitive functions, so techniques like redirection or "going along with" the person are indicated. However, when psychotic symptoms are due to a treatable illness, such as schizophrenia, the nurse should not say or do anything to reinforce the notion that the delusions or hallucinations are real in any way. This would only interfere with or impede the client's progress.The child's behavior is not acceptable and limits must be maintained.