Psychology Test 3 ~ Ch. 23

28. 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? a. A list of all medications the person currently takes b. Whether the person has experienced any recent losses c. Whether the person has ingested aged or fermented foods d. The person's recent personality characteristics and changes

ANS: A Delirium is often the result of medication interactions or toxicity. The distracters relate to MAOI therapy and depression. REF: Page 433-434 | Page 439 (Table 23-2)

6. A patient diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this patient? a. Provide a well-lit room without glare or shadows. Limit noise and stimulation. b. Maintain soft lighting day and night. Keep a radio on low volume continuously. c. Light the room brightly day and night. Awaken the patient hourly to assess mental status. d. Keep the patient by the nurse's desk while awake. Provide rest periods in a room with a television on.

ANS: A A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations. REF: Page 445 (Table 23-6) | Page 436 (Box 23-1) | Page 445 (Box 23-3) | Page 452 (Nursing Care Plan 23-1)

1. An older adult patient takes multiple medications daily. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of: a. delirium. b. dementia. c. amnestic syndrome. d. Alzheimer's disease.

ANS: A Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer's disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems. REF: Page 432

25. An older adult is prescribed digoxin (Lanoxin) and hydrochlorothiazide daily as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the patient's change in mental status? a. Drug actions and interactions b. Benzodiazepine withdrawal c. Hypotensive episodes d. Renal failure

ANS: A Drug actions and interactions are common among elderly persons and predispose this population to delirium. Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The patient takes lorazepam on a PRN basis, so withdrawal is unlikely. Hypotensive episodes or problems with renal function may occur associated with the patient's drug regime, but interactions are more likely the problem. REF: Page 433-434

16. An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful? a. Using the patient's glasses and hearing aids b. Placing personally meaningful objects in view c. Placing large clocks and calendars on the wall d. Assuring that the room is brightly lit but very quiet at all times

ANS: A Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations. REF: Page 434-436 (Box 23-1) | Page 445 (Box 23-3)

14. A patient has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Read one story from the newspaper to the patient every day.

ANS: A Patients with cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the patient is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the patient. Patients with cognitive deficits may enjoy the attention of someone reading to them, but this activity does not promote their function in the environment. REF: Page 445 (Table 23-6) | Page 447 (Table 23-7)

26. A hospitalized patient diagnosed with delirium misinterprets reality, while a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? The patients will: a. remain safe in the environment. b. participate actively in self-care. c. communicate verbally. d. acknowledge reality.

ANS: A Risk for injury is the nurse's priority concern. Safety maintenance is the desired outcome. The other outcomes are lower priorities and may not be realistic. REF: Page 435 | Page 442 | Page 452 (Nursing Care Plan 23-1)

20. Goals of care for an older adult patient diagnosed with delirium caused by fever and dehydration will focus on: a. returning to premorbid levels of function. b. identifying stressors negatively affecting self. c. demonstrating motor responses to noxious stimuli. d. exerting control over responses to perceptual distortions.

ANS: A The desired overall goal is that the delirious patient will return to the level of functioning held before the development of delirium. Demonstrating motor response to noxious stimuli is an indicator appropriate for a patient whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a patient with delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for a patient with sensorium problems related to delirium. REF: Page 435

21. An older adult with moderately severe dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient's family? a. Label the bathroom door. b. Take the older adult to the bathroom hourly. c. Place the older adult in disposable adult briefs. d. Limit the intake of oral fluids to 1000 ml per day.

ANS: A The patient with moderately severe dementia has memory loss that begins to interfere with activities. This patient may be able to use environmental cues such as labels on doors to compensate for memory loss. Regular toileting may be helpful, but a 2-hour schedule is often more reasonable. Placing the patient in disposable briefs is more appropriate at a later stage. Severely limiting oral fluid intake would predispose the patient to a urinary tract infection. REF: Page 443 (Table 23-4) | Page 447 (Table 23-7) | Page 449 (Table 23-9)

4. What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks c. Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations

ANS: A The physical safety of the patient is of highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful or when the patient exercises poor judgment or when the patient's sensorium is clouded. The other diagnoses may be concerns, but are lower priorities. REF: Page 435, Page 442-443 Page 452 (Nursing Care Plan 23-1)

2. Which assessment findings would the nurse expect in a patient experiencing delirium? Select all that apply. a. Impaired level of consciousness b. Disorientation to place, time c. Wandering attention d. Apathy e. Agnosia

ANS: A, B, C Disorientation to place and time is an expected finding. Orientation to person (self) usually remains intact. Attention span is short, and difficulty focusing or shifting attention as directed is often noted. Patients with delirium commonly experience illusions and hallucinations. Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is associated with depression. REF: Page 433 | Page 439 (Table 23-2)

MULTIPLE RESPONSE 1. A patient diagnosed with moderately severe Alzheimer's disease has a self-care deficit of dressing and grooming. Designate appropriate interventions to include in the patient's plan of care. Select all that apply. a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patient's name and name of the item. c. Administer anti-anxiety medication before bathing and dressing. d. Provide necessary items and direct the patient to proceed independently. e. If the patient resists dressing, use distraction and try again after a short interval.

ANS: A, B, E Providing clothing with elastic and hook-and-loop closures facilitates patient independence. Labeling clothing with the patient's name and the name of the item maintains patient identity and dignity (provides information if the patient has agnosia). When a patient resists, it is appropriate to use distraction and try again after a short interval because patient moods are often labile. The patient may be willing to cooperate given a later opportunity. Providing the necessary items for grooming and directing the patient to proceed independently are inappropriate. Be prepared to coach by giving step-by-step directions for each task as it occurs. Administering anxiolytic medication before bathing and dressing is inappropriate. This measure would result in unnecessary overmedication. REF: Page 443 (Table 23-4) | Page 447 (Table 23-7) | Page 452 (Nursing Care Plan 23-1)

You are preparing Genevieve, an 86 year old patient diagnosed with Alzheimer's Disease, for discharge and giving Discharge Education to Genevieve's Family, who will be caring for her. Which of the following intervention(s) would be beneficial to teach them? a. Recommend switching to hospital-type gowns to facilitate bathing, dressing, and other physical care of the patient b. Discourage wandering by installing complex locks or locks placed at the tops of doors where the patient cannot readily reach c. For situations in which the patient becomes upset, teach loved ones to listen briefly, provide support, and then change the topic d. Recognize the patient can no longer Successfully interact with others; Provide a darkened, quiet room for her to spend her time e. Encourage caregivers to care for themselves, as well as the patient, via use of support resources such as adult day care or respite care

ANS: A,B,C,E

Based on current research, which of the following patients is most likely to develop dementia? a. Karen, who works as an office manager in a high-stress environment b. Milo, who is a former boxer and is now a trainer c. Lilly, who works in a factory where asbestos is found d. Justin, who is a bartender in a dark underground club/bar

ANS: B

Rosa, a 78-year-old patient with Alzheimer's disease, picks up her glasses from the bedside table but does not recognize what they are or their purpose. She is experiencing: a. apraxia. b. agnosia. c. aphasia. d. agraphia.

ANS: B

7. Which assessment finding would be likely for a patient experiencing a hallucination? The patient: a. looks at shadows on a wall and says, "I see scary faces." b. states, "I feel bugs crawling on my legs and biting me." c. reports telepathic messages from the television. d. speaks in rhymes.

ANS: B A hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The other incorrect options apply to thought insertion and clang associations. REF: Page 432-434

12. Consider these diagnostic findings: apolipoprotein E (apoE) malfunction, neurofibrillary tangles, neuronal degeneration in the hippocampus, and brain atrophy. Which health problem corresponds to these diagnostic findings? a. Huntington's disease b. Alzheimer's disease c. Parkinson's disease d. Vascular dementia

ANS: B All of the options relate to dementias; however, the pathophysiological phenomena described apply to Alzheimer's disease. Parkinson's disease is associated with dopamine dysregulation. Huntington's disease is genetic. Vascular dementia is the consequence of circulatory changes. REF: Page 437-438

5. What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Distraction using sensory stimulation b. Careful observation and supervision c. Avoidance of physical contact d. Activation of the bed alarm

ANS: B Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient will remain safe and free from injury. Physical contact during care cannot be avoided. Activating a bed alarm is only one aspect of providing for the patient's safety. REF: Page 436 (Box 23-1) Page 452 (Nursing Care Plan 23-1)

18. During morning care, a nurse asks a patient diagnosed with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response? a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium

ANS: B Confabulation refers to making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The patient's response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario. REF: Page 438

13. A patient with stage 3 Alzheimer's disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time? a. Self-care deficit b. Impaired memory c. Caregiver role strain d. Adult failure to thrive

ANS: B Memory impairment begins at stage 2 and progresses in stage 3. This patient is able to perform most self-care activities. Caregiver role strain and adult failure to thrive occur later. REF: Page 439 (Table 23-2) | Page 442-443 (Table 23-5) | Page 452 (Nursing Care Plan 23-1)

19. A nurse counsels the family of a patient diagnosed with Alzheimer's disease who lives at home and wanders at night. Which action is most important for the nurse to recommend to enhance safety? a. Apply a medical alert bracelet to the patient. b. Place locks at the tops of doors. c. Discourage daytime napping. d. Obtain a bed with side rails.

ANS: B Placing door locks at the top of the door makes it more difficult for the patient with dementia to unlock the door because the ability to look up and reach upward is diminished. The patient will try to climb over side rails, increasing the risk for injury and falls. Avoiding daytime naps may improve the patient's sleep pattern but does not assure safety. A medical alert bracelet will be helpful if the patient leaves the home, but it does not prevent wandering or assure the patient's safety. REF: Page 449 (Table 23-9)

23. 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.

ANS: B Reorientation may seem like arguing to a patient with cognitive deficit and increases the patient's anxiety. Validating, talking with the patient about familiar, meaningful things, and reminiscing give meaning to existence both for the patient and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and placing large clocks and calendars strategically are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable because patients with dementia sometimes become more agitated with reorientation. REF: Page 445 (Table 23-6) | Page 445 (Box 23-3)

8. Consider these health problems: Lewy body disease, frontal-temporal lobar degeneration, and Huntington's disease. Which term unifies these problems? a. Cyclothymia b. Dementia c. Delirium d. Amnesia

ANS: B The listed health problems are all forms of dementia. REF: Page 437 | Page 451

27. 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. a. "The health care provider is the best person to answer your question." b. "The confusion will probably get better as we treat the infection." c. "Unfortunately, delirium is a progressively disabling disorder." d. "I will be glad to contact the chaplain to talk with you."

ANS: B Usually, as the underlying cause of the delirium is treated, the symptoms of delirium clear. The distracters mislead the family. REF: Page 433-434 | Page 439 (Table 23-2)

Intervention(s) appropriate for a hospitalized patient experiencing delirium include which of the following? Select all that apply. a. Immediately placing the patient in restraints if she begins to hallucinate or act irrationally or unsafely b. Assuring that a clock and a sign indicating the day and date is displayed where the patientcan see it easily c. Being prepared for possible hostile responses to efforts to take vital signs or provide direct physical care d. Preventing sensory deprivation by placing the patient near the nurses' station and leavingthe television and multiple lights turned on 24 hours per day e. Speaking with the patient frequently for short periods for reassurance, assisting thepatient in remaining oriented, and ensuring the patient's safety f. Anticipating that the patient may try to leave if agitated and providing for continuous direct observation to prevent wandering

ANS: B,C,E,F Restraint use tends to increase the patient's fear and resistance and should not be used unless all other options for reassuring the patient's safety have failed.

Trudy is a 72-year-old patient hospitalized with pneumonia and experiencing delirium. She points to her IV pole and screams, "Get him out of here! He's going to hurt me!" You recognize that what Trudy is experiencing is a(n): a. hallucination. b. delusion. c. illusion. d. confabulation.

ANS: C

10. An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia c. Agnosia d. Anhedonia

ANS: C Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. Anhedonia refers to a loss of joy in life. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 438 | Page 452 (Nursing Care Plan 23-1)

29. A nurse gives anticipatory guidance to the family of a patient diagnosed with stage 3, mild cognitive decline Alzheimer's disease. Which problem common to that stage should the nurse address? a. Violent outbursts b. Emotional disinhibition c. Communication deficits d. Inability to feed or bathe self

ANS: C 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. REF: Page 440 (Table 23-3) | Page 443 (Table 23-4) | Page 452 (Nursing Care Plan 23-1)

11. An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police intervened, they found that this adult was wearing a heavy coat and hat, even though it was July. Which stage of Alzheimer's disease is evident? a. Preclinical Alzheimer's disease b. Mild cognitive decline c. Moderately severe cognitive decline d. Severe cognitive decline

ANS: C In the moderately severe stage, deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. The individual has difficulty with clothing selection. Mild cognitive decline (early-stage) Alzheimer's can be diagnosed in some, but not all, individuals. Symptoms include misplacing items and misuse of words. In the stage of severe cognitive decline, personality changes may take place, and the patient needs extensive help with daily activities. This patient has symptoms, so the preclinical stage does not apply. REF: Page 438-439 (Table 23-2)

9. Which medication prescribed to patients diagnosed with Alzheimer's disease antagonizes N-Methyl-D-Aspartate (NMDA) channels rather than cholinesterase? a. Donepezil (Aricept) b. Rivastigmine (Exelon) c. Memantine (Namenda) d. Galantamine (Razadyne)

ANS: C Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterace inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimer's disease. REF: Page 450 (Table 23-10)

15. Two patients in a residential care facility have dementia. One shouts to the other, "Move along, you're blocking the road." The other patient turns, shakes a fist, and shouts, "You're trying to steal my car." What is the nurse's best action? a. Administer one dose of an antipsychotic medication to both patients. b. Reinforce reality. Say to the patients, "Walk along in the hall. This is not a traffic intersection." c. Separate and distract the patients. Take one to the day room and the other to an activities area. d. Step between the two patients and say, "Please quiet down. We do not allow violence here."

ANS: C Separating and distracting prevents escalation from verbal to physical acting out. Neither patient loses self-esteem during this intervention. Medication probably is not necessary. Stepping between two angry, threatening patients is an unsafe action, and trying to reinforce reality during an angry outburst will probably not be successful when the patients are cognitively impaired. REF: Page 445 (Table 23-6) | Page 452 (Nursing Care Plan 23-1)

2. A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs. Get them off!" Which problem is the patient experiencing? a. Aphasia b. Dystonia c. Tactile hallucinations d. Mnemonic disturbance

ANS: C The patient feels bugs crawling on both legs, even though no sensory stimulus is actually present. This description meets the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium. REF: Page 432-434

3. Which nursing diagnoses are most applicable for a patient diagnosed with severe Alzheimer's disease? Select all that apply. a. Acute confusion b. Anticipatory grieving c. Urinary incontinence d. Disturbed sleep pattern e. Risk for caregiver role strain

ANS: C, D, E The correct answers are consistent with problems frequently identified for patients with late-stage Alzheimer's disease. Confusion is chronic, not acute. The patient's cognition is too impaired to grieve. REF: Page 442-443 (Table 23-5) | Page 452 (Nursing Care Plan 23-1)

Claire is a student nurse working with Carl, an 82-year-old patient with dementia. She finds herself frustrated at times by not knowing how best to care for or communicate with Carl. Which of the following statements she could make to Carl illustrates best care practice? a. Lighthearted banter: "Carl, you look great today in your new sweater, you handsome devil!" b. Limit setting: "Carl, you cannot yell out in your room. You are upsetting other patients." c. Firm direction: "You will take a shower this morning; there is no debating about it so don't try to argue." d. Positive regard: "Carl, I am glad to be here caring for you today. Let's talk about your plans for the day."

ANS: D

Elaine is a 62-year-old patient who is recovering from a urinary tract infection during which she was hospitalized with delirium. She is following up with her primary care provider 4 weeks after being discharged. Based on research regarding possible postdelirium complications, what are important areas for the provider to assess at this time? a. Sleeping habits b. Sexual functioning c. Symptoms of posttraumatic stress d. Depression and level of cognition

ANS: D

17. A patient diagnosed with Alzheimer's disease calls the fire department saying, "My smoke detectors are going off." Firefighters investigate and discover that the patient misinterpreted the telephone ringing. Which problem is this patient experiencing? a. Hyperorality b. Aphasia c. Apraxia d. Agnosia

ANS: D Agnosia is the inability to recognize familiar objects, parts of one's body, or one's own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movements, such as being unable to dress. REF: Page 438

Mrs. Smith dies at the age of 82. In the 2 months following her death, her husband, aged 84 and in good health, has begun to pay less attention to his hygiene and seems less alert to his surroundings. He complains of difficulty concentrating and sleeping and reports that he lacks energy. His family sometimes has to remind and encourage him to shower, take his medications, and eat, all of which he then does. Which response is most appropriate? a. Reorient Mr. Smith by pointing out the day and date each time you have occasion to interact with him b. Meet with family and support persons to help them accept, anticipate, and prepare for the progression of his Stage II dementia c. Avoid touch and proximity; these are likely to be uncomfortable for Mr. Smith and may provoke aggression when he is disoriented d. Arrange for an appointment with a therapist for evaluation and treatment of suspected depression

ANS: D

Which statement about dementia is accurate? a. The majority of people over age 85 are affected by dementia b. Disorientation is the dominant and most disruptive symptom of dementia c. People with early dementia do not tend to be distressed by symptoms d. Hypertension, Diminished activity levels, and head injury increase the risk of dementia

ANS: D

A 73-year-old woman with pneumonia becomes agitated after being admitted to the intensive care unit through the emergency department. She is placed in soft restraints when she continues to try to leave her bed despite being too weak to walk. Her vital signs are erratic, and her thinking seems disorganized. During her first 24 hours in ICU, the patient varies from somnolent to agitated, and from laughing to angry. Her daughter reports that the patient "was never like this at home." What is the most likely explanation for the situation? A. Pneumonia has worsened the patient's early-stage dementia. B. The patient is sundowning due to the decreased stimulation of the intensive care unit. C. The patient does not want to be in the hospital and is angry that staff will not let her leave. D. The patient is experiencing delirium secondary to the pneumonia.

ANS: D While pneumonia may result in hypoxia which could aggravate the symptoms of dementia, the patient's daughter reports that this behavior is out of the ordinary. Delirium is always secondary to other disorders or causes (such as medications or fever), develops over a short period of time, and presents with emotional lability, unstable vital signs, fluctuating levels of consciousness, disorientation, and disorganized thinking—all of which exist in this case. The patient may well be angry about being hospitalized, but this would be an unlikely explanation for the constellation of symptoms and the patient's overall levels of mental deterioration since admission. Sundown syndrome is the development or worsening of behavioral problems due to reduced sensory input and relative lack of orientation aids (e.g., lighting) and is characterized by increasing disorientation as nightfall proceeds. In this case, the patient's behavioral changes are occurring and changing in a manner seemingly unrelated to the time of day (e.g., persisting through a 24-hour period).

24. What is the priority need for a patient with late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Preventing the patient from wandering d. Maintenance of nutrition and hydration

ANS: D In late-stage dementia, the patient often seems to have forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the patient is to live. The patient is incapable of self-care, ambulation, or verbal communication. REF: Page 440 (Table 23-3)

22. A older patient diagnosed with severe, late-stage dementia no longer recognizes family members. The family asks how long it will be before this patient recognizes them when they visit. What is the nurse's best reply? a. "Your family member will never again be able to identify you." b. "I think that is a question the health care provider should answer." c. "One never knows. Consciousness fluctuates in persons with dementia." d. "It is disappointing when someone you love no longer recognizes you."

ANS: D Therapeutic communication techniques can assist the family to come to terms with the losses and irreversibility dementia imposes on both the loved one and themselves. Two incorrect responses close communication. The nurse should take the opportunity to foster communication. Consciousness does not fluctuate in patients with dementia. REF: Page 438 | Page 440 (Table 23-3) | Page 441 | Page 443 (Table 23-5)

3. A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response? a. "No bugs are on your legs. You are having hallucinations." b. "I will have someone stay here and brush off the bugs for you." c. "Try to relax. The crawling sensation will go away sooner if you can relax." d. "I don't see any bugs, but I can tell you are frightened. I will stay with you."

ANS: D When hallucinations are present, the nurse should acknowledge the patient's feelings and state the nurse's perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patient's perception without offering help does not support the patient emotionally. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions. REF: Page 436 (Box 23-1)