Chapter 24: Cognitive Disorders PREP U
A 35-year-old client is delirious after being lost in the woods for several days and becoming severely dehydrated. At 9 p.m. the client tells the nurse to get the client's clothes because the client has to get home to the client's family. Which response by the nurse is most therapeutic? "It's time to sleep now; you can see your family in the morning." "We don't have your clothes; they are at home. You'll be going home when you recover." "Your family is fine. You need to take care of yourself now." "You're in the hospital. You did not drink for several days, but you're getting better now."
"You're in the hospital. You did not drink for several days, but you're getting better now." Staff members can try to direct the client's activity and cognitive focus by reorienting the client to the environment with displays of calendars, clocks, and decorations commemorating upcoming holidays. Therapeutic communications concerning the day's activities, repetition of facts concerning why the client is hospitalized, and reassurance that the hallucinations and delusions experienced are part of the transient condition of delirium are helpful.
A client diagnosed with Alzheimer's disease has an alteration in language ability. This alteration would be documented as what? Akinesia Apraxia Agnosia Aphasia
Aphasia Aphasia is an alteration in language ability. Agnosia is the failure to recognize or identify objects despite intact sensory function. Apraxia is impairment in the ability to execute motor activities despite intact motor functioning. Akinesia is impaired muscle movement that may occur in Parkinson's disease.
An older client has recently finished treatment for a urinary tract infection (UTI) and has now developed changes in behavior resulting in decreased cognition. Which priority intervention(s) should the nurse perform? Select all that apply. Obtain a repeat urine culture. Contact the health care provider. Stop the prescribed antibiotic therapy. Maintain adequate hydration. Obtain an order for sedation.
Contact the health care provider. Maintain adequate hydration. Obtain a repeat urine culture.
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? Give the client a sedative when the client begins to get agitated. Distract the client with family photos and discuss the events pictured. Distract the client by turning on the television or watching a video. Leave the client in a safe place in the house and go to another area until the client calms down.
Distract the client with family photos and discuss the events pictured. 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 client with Alzheimer's disease is admitted to an acute care facility for treatment of an infection. Assessment reveals that the client is anxious. When developing the client's plan of care, which would be least appropriate for a nurse to include? Frequently provide reality orientation Simplify the client's routines Limit the number of choices to be made Establish predictable routines
Frequently provide reality orientation
Which is a metabolic cause of delirium? Hypoglycemia Alcohol Intoxication Encephalitis Meningitis
Hypoglycemia Hypoglycemia is a metabolic cause of delirium. Meningitis and encephalitis are infection-related causes. Alcohol intoxication is a drug related cause of delirium.
Cognitive disorders are characterized by what? Distorted self-image Impaired adjustment to stressful events Impaired attention, memory, and abstract thinking Negative self-talk and poor coping skills
Impaired attention, memory, and abstract thinking
While reviewing the medical record of a client diagnosed with moderate dementia of the Alzheimer type, a nurse notes that the client has been receiving memantine. The nurse identifies this drug as which type? Atypical antipsychotic Cholinesterase inhibitor Benzodiazepine N-methyl-D-aspartate (NMDA) receptor antagonist
N-methyl-D-aspartate (NMDA) receptor antagonist Memantine is classified as an NMDA receptor antagonist that has been shown to improve cognition and activities of daily living in clients with moderate to severe symptoms of dementia. Risperidone, olanzapine, and quetiapine are examples of atypical antipsychotics. Galantamine, donepezil, rivastigmine, and tacrine are cholinesterase inhibitors. Clonazepam, alprazolam, and lorazepam are examples of benzodiazepines.
Which is an infection-related cause of delirium? Sleep deprivation Pneumonia Renal failure Lithium toxicity
Pneumonia Infection-related causes of delirium include pneumonia, sepsis, urinary tract infection, and meningitis. Lithium toxicity is a drug-related cause. Renal failure and sleep deprivation are physiologic causes.
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 have a diagnosis of dementia? Irrelevant speech Remote memory loss Visual hallucinations Impaired consciousness
Remote memory loss Impaired memory may be present in both delirium and dementia. However, remote memory loss, which can manifest as forgetting the names of adult children, the client's former occupation, or even the client's own name, occurs in the later stages of dementia. Irrelevant speech, visual hallucinations, and impaired consciousness are signs of delirium. In dementia, speech is normal during the initial stages and then progresses to aphasia. Hallucinations may be present in dementia but are typical of delirium. Consciousness is usually not impaired in client with dementia.
Which nursing diagnosis would be the priority for the client experiencing acute delirium? Risk for injury related to confusion and cognitive deficits Acute confusion related to delirium of known/unknown etiology Risk for self-mutilation related to confusion and cognitive deficits Fall precautions related to acute confusion
Risk for injury related to confusion and cognitive deficits The plan of care must be deliberately designed to meet the client's unique needs, with safety always being the nurse's highest priority. Risk for injury is a NANDA diagnosis and the etiology of confusion and cognitive deficits are factors that can be modified through nursing care.
Which can be identified as a hallmark symptom of dementia? Long-term memory affected most Clients with these disorders tend to confabulate Short-term memory loss This class of disorders does not involve memory loss
Short-term memory loss 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 psychiatric nurse documents that the cognitively impaired client is exhibiting "confabulation" when observed doing what? Pacing nervously and resisting the staff's request to "get ready for bed" Telling the staff repeatedly that "my name is George and I'm hungry" Telling other clients that the client "was a dairy farmer" when the client actually ran a small grocery store Asking where the cats are when told it's "raining cats and dogs"
Telling other clients that the client "was a dairy farmer" when the client actually ran a small grocery store
Question 17 of 20 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. The client identifies the client's fork as a spoon. The client has trouble remembering the client's birth date. The client cannot brush the client's teeth.
The client removes the client's surgical bandage and begins picking at the sheets. 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. The client will be physically stable, maintain normal body weight, and be safe. The client will be safe and eat appropriately. The client will have no self-harm behaviors and maintain sleep and appetite.
The client will be safe, be physiologically stable, and have infrequent episodes of agitation. 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.
A group of friends have arrived at the hospital to visit a client recently diagnosed with delirium. The nurse tells the friends they can visit with the client one at a time. What is the likely reason for the nurse to give this instruction? The nurse wants to ensure the client's safety. The nurse wants to prevent increasing the client's confusion. The nurse wants the client to demonstrate good orientation. The nurse wants the client to maintain an adequate balance of activity and rest.
The nurse wants to prevent increasing the client's confusion
Which type of hallucination is most commonly seen in clients diagnosed with DEMENTIA? Visual Auditory Gustatory Autonomic
Visual
The nurse documents that a client diagnosed with dementia of the Alzheimer's type is exhibiting agnosia when the client is observed being unable to ... identify a picture of a car. find words to describe the client's daughter's appearance. open juice and insert a straw into the container. button a blouse.
identify a picture of a car. Agnosia is the failure to recognize or identify objects despite intact sensory function, so the nurse documents that a client diagnosed with dementia of the Alzheimer's type is exhibiting it when the client is observed being unable to identify a picture of a car. Apraxia is the impaired ability to carry out motor activities despite motor function; aphasia is the presence of language disturbance; and disturbances in executive functioning manifest in things like the inability to open a juice container.
What is the greatest benefit support groups provide to the caregivers of clients diagnosed with dementia? provides interaction with those with similar concerns provides resources for needed services provides a social outlet provides time away from the client
provides interaction with those with similar concerns 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.
Which client behavior should the nurse attempt to change when managing a client's tendency to wander and pace at night? insist on having the curtains left open at night watch television after dinner request a bedtime snack of milk and cookies take a nap mid-afternoon and before dinner
take a nap mid-afternoon and before dinner Clients with dementia often experience disturbed sleep-wake cycles; they nap during the day and wander at night. This behavior can contribute to the nighttime activity. The other options are not likely to affect sleep cycles.
A group of student nurses are reviewing diagnostic criteria for the clinical diagnosis of Alzheimer disease (AD). Which finding(s) indicates that a client may have AD? Select all that apply. abnormal chemistry profile intact remote memory unable to identify a pen unable to verbally communicate inability to use a telephone
unable to identify a pen unable to verbally communicate inability to use a telephone
When assessing a client with DEMENTIA, a nurse identifies that the client is experiencing hallucinations. Based on the nurse's understanding of this disorder, which type of hallucination would the nurse expect as MOST common? Auditory Visual Gustatory Olfactory
visual
Which type of hallucination most commonly occurs in clients diagnosed with DEMENTIA? Visual Auditory Gustatory Olfactory
Visual
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? "Are you aware of your parent falling or injuring the head in any way?" "Has your parent experienced any major losses recently?" "Has your parent taken any medications recently?" "Has your parent had a recent stroke?" SUBMIT ANSWER
"Has your parent taken any medications recently?" 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.
In clients with Alzheimer's disease, neurotransmission is reduced, neurons are lost, and the hippocampal neurons degenerate. Which neurotransmitter is most involved in cognitive functioning? Acetylcholine Norepinephrine Epinephrine Serotonin
Acetylcholine Acetylcholine is involved in cognitive functioning. Epinephrine, serotonin, and norepinephrine are not as involved in cognitive functioning.
The nurse is caring for a client with dementia. The client's brain images show atrophy of cerebral neurons and enlargement of the third and fourth ventricles. What is the cause of dementia in this client? Picks's disease Parkinson's disease Alzheimer's disease Vascular dementia
Alzheimer's disease The client's brain images show atrophy of cerebral neurons and enlargement of the third and fourth ventricles. These findings are indicative of Alzheimer's disease. In PICKS disease, there is degeneration of frontal and temporal lobes. [think of a pig-picks the frontal and temporal love for hunch back]In vascular dementia there are multiple vascular lesions of the cerebral cortex and subcortical structures. In Parkinson's disease, the primary pathology is the loss of neurons in the basal ganglia.
What is the primary sign of delirium? An altered level of consciousness Impaired socialization Disturbed sleep-wake cycles Inability to fulfill roles
An altered level of consciousness
The nurse is performing an admission assessment for a client who is suspected of having dementia. Which finding would the nurse most likely document as a subjective finding? Results of testing the client's ability to remember unrelated words and recent events Client's ability to perform arithmetic problems to determine cortical function Assessment of the client's level of consciousness Answers by the client and family to questions about emotional changes
Answers by the client and family to questions about emotional changes Answers to question posed to the client or family about emotional changes would be documented as subjective findings. Testing the client's ability to remember unrelated words and recent events, assessing the client's level of consciousness, and determining cortical function by the client's ability to perform arithmetic are all objective assessments.
When conducting a nursing assessment of a client experiencing moderate cognitive dysfunction, the nurse can best prepare for an effective interview by ensuring what? Breaking up the assessment into several short periods rather than a continuous one Sitting beside the client and using touch to be supportive Asking a family member to be present during the assessment Being sure the client is well rested before beginning the interview
Asking a family member to be present during the assessment The assessment will require the support provided by close family or a friend since moderate dysfunction will definitely interfere with concentration and memory. Family members can help to fill in gaps during the assessment where this function may be challenging and frustrating for the client.
When giving tacrine to an elderly client, the nurse must be aware of what information? The most common side effects are headache and dizziness, so the client must be monitored for falls. Tacrine works only in clients with late-stage dementia. Because the liver is most vulnerable to tacrine, liver function tests must be done periodically. The client will experience dry mouth and difficulty urinating.
Because the liver is most vulnerable to tacrine, liver function tests must be done periodically. The liver rapidly absorbs and metabolizes tacrine; therefore, the liver is most vulnerable to the drug's toxicity.
Changes that are found during the mental status examination of a client diagnosed with delirium include what? Difficulty focusing Clear memory No impairment of consciousness Increased attention to detail
Difficulty focusing The mental status evaluation reveals several changes, including fluctuations in level of consciousness with reduced awareness of the environment; difficulty focusing and sustaining attention, or difficulty shifting attention; and severely impaired memory, especially immediate and recent memory.
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? Skin rashes Syncope Gastrointestinal (GI) symptoms Bruising
Gastrointestinal (GI) symptoms [chooorroo]
A client with amnestic disorder is being evaluated for dementia. Which is a diagnostic characteristic of amnestic disorder? Memory minimally decreased from usual No significant problems with occupational or social functioning History and physical examination indicative of memory impairment Memory impairment limited to periods of delirium
History and physical examination indicative of memory impairment Diagnostic characteristics of amnestic disorder include memory impairment not solely limited to periods of delirium, history and physical examination indicative of medical condition underlying the memory impairment, demonstration of significant problems with social or occupational functioning, and memory significantly decreased from usual level.
A nurse is preparing a presentation for a group of staff nurses about neurocognitive disorders. When describing vascular neuorocognitive disorder, the nurse would identify which as posing the greatest risk for this disorder? Diabetes Hyperlipidemia Heart disease Hypertension
Hypertension Vascuar neurocognitive disorder involves a series of small strokes that damage or destroy brain tissue. The primary causes of these strokes include high blood cholesterol levels, diabetes, heart disease, and high blood pressure. Of these, high blood pressure is the greatest risk factor for vascular neurocognitive disorder.
A client with dementia is having difficulty clearly communicating about physical needs. When teaching the caregiver about ways to assist the client in meeting physical needs, which instruction would the nurse most likely include? Give acetaminophen if the client appears uncomfortable. Keep a record of bowel movements. Keep a record of emotional outbursts. Ensure environmental noise for stimulation.
Keep a record of bowel movements. Adequate nutrition, bowel and bladder function are important physical needs. Maintenance of nutrition and hydration are essential nursing interventions. The patient's weight, oral intake, and hydration status should be monitored carefully. Poor food and fluid intake can result in bowel and bladder problems. Constipation or impaction from insufficient bulk or water can have serious consequences if not treated promptly. The client may be unable to articulate feelings of fullness; caregivers should keep a record of the regularity of bowel movements. Overstimulation should be avoided. Keeping a record of emotional outbursts is unrelated to the client's physical needs.
Which medication is not known to cause delirium? Antidepressants Steroids Narcotics Loop diuretics
Loop diuretics Loop diuretics are not known to causes delirium. Steroids, narcotics, and antidepressants may cause delirium.
Which of these is a N-methyl-D-aspartic acid (NMDA) receptor antagonist? Rivastigmine Galantamine Memantine Donepezil
Memantine 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 group of nursing students is reviewing information about delirium and its causes. The students demonstrate a need for ADDITIONAL REVIEW when they identify which as a cause of this medical condition? Oxidative stress Electrolyte imbalance Medications Infection
Oxidative stress Oxidative stress is associated with dementia. The etiology of delirium is complex and multifaceted. Delirium is associated with medications, infections, fluid and electrolyte imbalance, metabolic disturbances, or hypoxia or ischemia. The probability of the syndrome developing increases if certain predisposing factors, such as advanced age, brain damage, or dementia, are also present. Sensory overload or underload, immobilization, sleep deprivation, and psychosocial stress also contribute to delirium.
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? Have the client eat in the client's room to avoid distractions while eating. Provide the client with a tray, opening containers for the client. Provide the client with a tray but encourage the client to open the client's own packages. Ask the client what the client would like from the buffet and give the client finger foods.
Provide the client with a tray, opening containers for the client. 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.
An older client transferred from a nursing home presents to the emergency department in an agitated state. The nurse is unable to obtain a coherent response to any questions posed. What is the best nursing action? Review medication profile record. Sedate the client with medication. Make sure all side rails are up. Place the client in restraints to maintain safety.
Review medication profile record. At the present time, additional information is needed to determine whether the older client is experiencing delirium or dementia; therefore, the priority would be to review the medication profile record to see if any prescribed medications are causing delirium. Although the client is agitated, there is insufficient evidence for the use of restraints and using them could cause the confusion to worsen. Making sure that all side rails are up is a form of a restraint. Sedating the client with medication may eventually be needed. but it is not the priority action. The nurse must identify the cause of confusion and agitation prior to using medications.
A client is diagnosed with dementia related to Parkinson's disease. While at a clinic visit, a cholinesterase inhibitor is prescribed for the client. The nurse knows that this type of medication would be prescribed for the client to achieve which goal? Decrease tremors associated with Parkinson's disease Increase the number of neurons in the brain Decrease combative behaviors and hallucinations Slow deterioration of memory and function
Slow deterioration of memory and function Compelling evidence shows that drugs that inhibit acetylcholine (ACh) destruction or increase cholinergic activity can slow deterioration of memory and function. Cholinesterase inhibitors increase availability of ACh by interfering with the enzyme that breaks it down. These centrally acting drugs help elevate the level of ACh by decreasing the binding sites of acetylcholinesterase, which lengthens the potential for cholineregic activity.
Which medication used to treat dementia requires a liver function test every 1 to 2 weeks? Galantamine Tacrine Rivastigmine Donepezil
Tacrine
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 showing signs of agnosia in that the client is unable to name the client's children. The client demonstrates aphasia when discussing the client's children. The client is confused about the client's children and needs refocusing. The client is confabulating, most likely to cover for memory deficit.
The client is confabulating, most likely to cover for memory deficit. 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's speech may be vague and cannot be interpreted. The client may have extreme difficulty forming sentences. The client may repeat words or sounds over and over. The client may echo whatever is heard.
The client may echo whatever is heard. 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.
The nurse is interviewing a 50-year-old with a suspected cognitive disorder. The client has a long history of alcoholism. When the nurse asks if the client is employed, the client replies that the client is currently employed as a conductor on a national railway system. The client's spouse takes the nurse aside and informs the nurse that the client hasn't worked for several years and never worked for the railway. The nurse attributes the client's answer to which explanation? The client is ashamed that the client is unemployed and is trying to cover for it. The client may have Alzheimer's disease. The client may be going through alcohol withdrawal. The client may have Korsakoff's syndrome.
The client may have Korsakoff's syndrome. Korsakoff's syndrome usually is found in the 40- to 70-year-old client with alcoholism and a history of steady and progressive alcohol intake. In time, this person develops a vitamin B1 (thiamin) deficiency that directly interferes with the production of the brain's main nutrient, glucose, resulting in the symptomatology of this syndrome. A client with this disorder has great difficulty with recent memory, specifically the ability to learn new information. Because of the inability to recall recent events, the individual fills in memory gaps with fabricated or imagined data (confabulation)
The nurse asks a client to pretend the client is brushing the client's teeth. The client is unable to perform the action. Upon examination, the nurse finds that the client possesses intact motor abilities. What can this problem be documented as? The client may have apraxia. The client may have disturbed executive function. The client may have agnosia. The client may have aphasia.
The client may have apraxia. Impaired ability to execute motor functions despite having intact motor abilities is referred to as apraxia. In this case, the client knows how to and has the physical abiltiy to brush the client's teeth but is unable to demonstrate the action upon request. Thus the client has apraxia. The inability to recognize or name objects or sounds heard is referred to as agnosia. Aphasia is the deterioration of language function. Disturbed executive function is the inability to carry out complex motor activities. Using a toothbrush is not a complex activity.
The diagnosis of delirium is supported when the nurse notes what about the client? The client repeatedly asks where the client is and attempts to drink the water in a flower vase The client responds to most assessment questions with "I don't know" and appears apathetic The client spends much of the day sleeping in the dayroom and usually denies being hungry The client reports seeing "hundreds of bugs" and is not always oriented to time and place
The client reports seeing "hundreds of bugs" and is not always oriented to time and place The diagnosis of delirium is supported when the nurse documents that the client is convinced that the client sees hundreds of bugs and is not always oriented to time and place. Repeatedly asking about location and attempting to drink the water in a flower vase are more characteristic of dementia than delirium. Spending much of the day sleeping in the dayroom and usually denying being hungry are more representative of depression, as are responding to most assessment questions with "I don't know" and appearing apathetic.
A 59-year-old has just been diagnosed with early-stage dementia. The client is experiencing mild forgetfulness but can function normally. The client lives with a spouse and adult child, who is a single parent of two. When planning care for this family, which of the goals should the nurse identify as a priority? The client will discuss emotional response to diagnosis. The client will maintain self-care abilities as long as possible. The family will identify resources to meet caregiving needs. The caregivers will demonstrate effective coping strategies to prevent burnout.
The client will discuss emotional response to diagnosis
A 59-year-old has just been diagnosed with early-stage dementia. The client is experiencing mild forgetfulness but can function normally. The client lives with a spouse and adult child, who is a single parent of two. When planning care for this family, which of the goals should the nurse identify as a priority? The client will maintain self-care abilities as long as possible. The client will discuss emotional response to diagnosis. The caregivers will demonstrate effective coping strategies to prevent burnout. The family will identify resources to meet caregiving needs.
The client will discuss emotional response to diagnosis. The client with dementia benefits from as early a diagnosis as possible to allow for interventions that slow the disorder's progression. The treatment team interacts most intensively with the client during the early stages of dementia, when he or she is still aware of and thus most frustrated and depressed about cognitive losses. As the client's cognitive abilities and behavior deteriorate, the needs of the client and family become more extensive.
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? Medication therapy Injury prevention Functional independence Therapeutic relationship
Therapeutic relationship 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.
A nurse is caring for a client with delirium. The nurse assesses the client's activities of daily living on a daily basis. What is the most likely reason for assessing these so frequently? To ensure the client is involved in therapy To assess the prognosis of the client after therapy To ensure the client establishes a daily routine To assess for fluctuation in the client's capabilities
To assess for fluctuation in the client's capabilities Clients with organic diseases like delirium tend to have fluctuations in their ability to carry out activities of daily living. Thus, the nurse should assess these daily. Although the nurse should encourage the client to make decisions about treatment and assist the client in establishing a daily routine, these actions do not require daily assessment. Assess the prognosis of the client after therapy also is not required daily.
An older adult with no significant medical history is admitted to the hospital through the emergency department after hitting the client's head during a fall and fracturing the humerus. The client does not require surgery and will probably be discharged the following day. Should the nurse be concerned about delirium? No, because the client does not have an underlying disease process Yes, because of the head injury and medication Yes, because the client is in an unfamiliar environment and overstimulated No, because the client will not be hospitalized long enough to develop delirium
Yes, because of the head injury and medication This client is an older adult who has suffered trauma and, given the injuries, is likely receiving medication for pain. Certain clients are at increased risk for delirium, specifically older adults and cognitively impaired older adults recovering from surgery. Older adults are especially susceptible to delirium disorders because the aging neurologic system is particularly vulnerable to insults caused by underlying systemic conditions. Indeed, delirium often predicts or accompanies physical illness in older adults. An underlying disease process is not necessary for this injured older adult to be at risk for delirium, and length of hospitalization is irrelevant. While an unfamiliar environment and overstimulation can exacerbate delirium, these are not risk factors for developing it.