Chapter 11

11 Cognitive Impairment Disorders 1. The nurse enters the room of a client with a cognitive impairment disorder and asks what day of the week it is; what the date, month, and year are; and where the client is. The nurse is attempting to assess: 1. confabulation. 2. delirium. 3. orientation. 4. perseveration.

Hide Answer 1. The answer is 3. The initial, most basic assessment of a client with cognitive impairment involves determining his level of orientation (awareness of time, place, and person). The nurse may also assess for confabulation and perseveration in a client with cognitive impairment; but the questions in this situation would not elicit the symptom response. Delirium is a type of cognitive impairment; however, other symptoms are necessary to establish this diagnosis.

10. In clients with a cognitive impairment disorder, the phenomenon of increased confusion in the early evening hours is called: 1. aphasia. 2. agnosia. 3. sundowning. 4. confabulation.

Hide Answer 10. The answer is 3. Sundowning is a common phenomenon that occurs after daylight hours in a client with a cognitive impairment disorder. The other options are incorrect responses, although all may be seen in this client.

11. An 80-year-old man is accompanied to the clinic by his son, who tells the nurse that the client's constant confusion, incontinence, and tendency to wander are intolerable. The client was diagnosed with chronic cognitive impairment disorder. Which nursing diagnosis is most appropriate for the client's son? 1. Risk for other-directed violence 2. Disturbed sleep pattern 3. Caregiver role strain 4. Social isolation

Hide Answer 11. The answer is 3. The son's description exemplifies some of the problems commonly encountered by a primary caregiver who is caring for someone with a cognitive impairment disorder. Although the other nursing diagnoses are possibilities, the scenario does not provide enough information to validate any of these.

12. Which of the following outcome criteria is appropriate for the client with dementia? 1. The client will return to an adequate level of self-functioning. 2. The client will learn new coping mechanisms to handle anxiety. 3. The client will seek out resources in the community for support. 4. The client will follow an established schedule for activities of daily living.

Hide Answer 12. The answer is 4. Following established activity schedules is a realistic expectation for clients with dementia. All of the remaining outcome statements require a higher level of cognitive ability than can be realistically expected of clients with this disorder.

13. A family member expresses concern to a nurse about behavioral changes in an elderly aunt. Which would cause the nurse to suspect a cognitive impairment disorder? 1. Decreased interest in activities that she once enjoyed 2. Fearfulness of being alone at night 3. Increased complaints of physical ailments 4. Problems with preparing a meal or balancing her checkbook

Hide Answer 13. The answer is 4. Making a meal and balancing a checkbook are higher level cognitive functions that, when unable to be performed, may signal onset of a cognitive disorder. Although the remaining behaviors may occur, they are not associated only with cognitive impairment and may indicate depression or other problems.

14. During the home visit of a client with dementia, the nurse notes that an adult daughter persistently corrects her father's misperceptions of reality, even when her father becomes upset and anxious. Which intervention should the nurse teach the caregiver? 1. Anxiety-reducing measures 2. Positive reinforcement 3. Reality orientation techniques 4. Validation techniques

Hide Answer 14. The answer is 4. Validation techniques are useful measures for making emotional connections with a client who can no longer maintain reality orientation. These measures are also helpful in decreasing anxiety. Anxiety-reducing measures and positive reinforcements will also be appropriate, but validation techniques will provide both anxiety reduction and positive reinforcement for the client. Reality orientation techniques are not useful when the client can no longer maintain reality contact and becomes upset when misperceptions are corrected.

15. A client with moderate dementia has frequent catastrophic reactions during shower time. Which of the following interventions should be implemented in the plan of care? Select all that apply. 1. Assign consistent staff members to assist the client. 2. Accomplish the task quickly, with several staff members assisting. 3. Schedule the client's shower at the same time of day. 4. Sedate the client 30 minutes prior to showering. 5. Tell the client to remain calm while showering. 6. Use a calm, supportive, quiet manner when assisting the client.

Hide Answer 15. The answer is 1, 3, 6. Maintaining a consistent routine with the same staff members will help decrease the client's anxiety that occurs whenever changes are made. A calm, quiet manner will be reassuring to the client, also helping to minimize anxiety. Moving quickly with several staff will increase the client's anxiety and may precipitate a catastrophic reaction. The use of sedation is not indicated and may increase the risk of client injury from side effect of drowsiness. Telling the client to remain calm is inappropriate because a client with dementia cannot respond to such a direction.

2. Which of the following best describes dementia? 1. Memory loss occurring as part of the natural consequence of aging 2. Difficulty coping with physical and psychological change 3. Severe cognitive impairment that occurs rapidly 4. Loss of cognitive abilities, impairing ability to perform activities of daily living

Hide Answer 2. The answer is 4. The impaired ability to perform self-care is an important measure of a client's dementia progression and loss of cognitive abilities. Difficulty or impaired ability to perform normal activities of daily living, such as maintaining hygiene and grooming, toileting, making meals, and maintaining a household, are significant indications of dementia. Slowing of processes necessary for information retrieval is a normal consequence of aging. However, the global statement that memory loss occurs as part of natural aging is not true. Dementia is not normal; it is a disease. Difficulty coping with changes can be experienced by any client, not just one with dementia. The rapid occurrence of cognitive impairment refers to delirium.

3. Which of the following will the nurse use when communicating with a client who has a cognitive impairment? 1. Complete explanations with multiple details 2. Pictures or gestures instead of words 3. Stimulating words and phrases to capture the client's attention 4. Short words and simple sentences

Hide Answer 3. The answer is 4. Short words and simple sentences minimize client confusion and enhance communication. Complete explanations with multiple details and stimulating words and phrases would increase confusion in a client with short attention span and difficulty with comprehension. Although pictures and gestures may be helpful, they would not substitute for verbal communication.

4. A 75-year-old client has dementia of the Alzheimer's type and confabulates. The nurse understands that this client: 1. denies confusion by being jovial. 2. pretends to be someone else. 3. rationalizes various behaviors. 4. fills in memory gaps with fantasy.

Hide Answer 4. The answer is 4. Confabulation is a communication device used by patients with dementia to compensate for memory gaps. The remaining answer choices are incorrect.

5. Which ability should a nurse expect from a client in the mild stage of dementia of the Alzheimer's type? 1. Remembering the daily schedule 2. Recalling past events 3. Coping with anxiety 4. Solving problems of daily living

Hide Answer 5. The answer is 2. Recent memory loss is the characteristic sign of cognitive difficulty in early Alz-heimer's disease. The ability to recall past events is usually retained until the later stages of this disorder. Remembering daily schedules, coping with anxiety, and solving problems of daily living are areas that would pose difficulty in the early phase of Alzheimer's disease.

6. An 82-year-old man is admitted to the medical-surgical unit for diagnostic confirmation and management of probable delirium. Which statement by the client's daughter best supports the diagnosis? 1. "Maybe it's just caused by aging. This usually happens by age 82." 2. "The changes in his behavior came on so quickly! I wasn't sure what was happening." 3. "Dad just didn't seem to know what he was doing. He would forget what he had for breakfast." 4. "Dad has always been so independent. He's lived alone for years since Mom died."

Hide Answer 6. The answer is 2. Delirium is an acute process characterized by abrupt, spontaneous cognitive dysfunction. Cognitive impairment disorders (dementia or delirium) are not normal consequences of aging. Option 3 would be characteristic of someone with dementia. Although option 4 provides background data about the client, it is unrelated to the current problem of delirium.

7. An elderly client with Alzheimer's disease becomes agitated and combative when a nurse approaches to help with morning care. The most appropriate nursing intervention in this situation would be to: 1. tell the client firmly that it is time to get dressed. 2. obtain assistance to restrain the client for safety. 3. remain calm and talk quietly to the client. 4. call the doctor and request an order for sedation.

Hide Answer 7. The answer is 3. Maintaining a calm approach when intervening with an agitated client is extremely important. Telling the client firmly that it is time to get dressed may increase his agitation, especially if the nurse touches him. Restraints are a last resort to ensure client safety and are inappropriate in this situation. Sedation should be avoided, if possible, because it will interfere with CNS functioning and may contribute to the client's confusion.

8. Which goal is a priority for a client with a DSM-IV TR diagnosis of delirium and the nursing diagnosis Acute confusion related to recent surgery secondary to traumatic hip fracture ? 1. The client will complete activities of daily living. 2. The client will maintain safety. 3. The client will remain oriented. 4. The client will understand communication.

Hide Answer 8. The answer is 2. Maintaining safety is the priority goal for an acutely confused client who recently had surgery. All measures to promote physiologic safety and psychosocial well-being would be implemented. This client would not be capable of completing activities of daily living, and safety is a priority over these tasks. The goals of remaining oriented and understanding communication would be appropriate only after the client's acute confusion has resolved.

9. Which of the following is not included in the care plan of a client with a moderate cognitive impairment involving dementia of the Alzheimer's type? 1. Daily structured schedule 2. Positive reinforcement for performing activities of daily living 3. Stimulating environment 4. Use of validation techniques

Hide Answer 9. The answer is 3. A stimulating environment is a source of confusion and anxiety for a client with a moderate level of impairment and, therefore, would not be included in the plan of care. The remaining options are all appropriate interventions for this client.