Mental Health- NeuroCognitive Disorders

Which description best applies to a hallucination? a. A patient states, "I feel bugs crawling on my legs and biting me." b. A patient looks at shadows on a wall and tells the nurse, "I see scary faces." c. A patient becomes anxious whenever the nurse leaves the bedside. d. A patient tries to hit the nurse when vital signs are being taken.

ANS: A 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 remaining options are examples of behaviors that sometimes occur during delirium and are related to fluctuating levels of awareness and misinterpreted stimuli.

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

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.

Which planned assessments are of critical importance for a patient with delirium? a. Biophysical parameters b. The emotional state c. Speech and language d. Cognitive symptoms

ANS: A Although each area should be assessed initially and systematically thereafter, the biophysical parameters, including vital signs and physical safety needs, are of critical importance to maintenance of biophysical integrity. Delirium is a physiological disturbance.

An independent, older adult patient takes digoxin and hydrochlorothiazide daily as well as lorazepam (Ativan) as needed for anxiety. Today, a visiting neighbor found the patient confused with slurred speech and an unsteady gait. At the emergency department, the nurse assessed memory and attention deficits and fluctuating levels of orientation. The neighbor says the patient's symptoms developed over a 2-day period. 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.

A patient with Alzheimer's disease needs coaching to bathe and dress, wanders aimlessly throughout the home, has mood fluctuations from pleasant to irritable, and becomes frustrated when performing simple tasks. Which behavior is an example of a cognitive impairment? a. Inability to bathe and dress independently b. Wandering c. Mood lability d. Ease of frustration

ANS: A Inability to bathe and dress suggests apraxia, the loss of purposeful movement in the absence of motor or sensory impairment. The other symptoms are less directly attributable to loss of cortical function.

Which nursing intervention is designed to help a patient with progressive memory deficit associated with dementia function in the environment? a. Assisting the patient to perform simple tasks by giving step-by-step directions b. Reducing frustration by performing activities of daily living for the patient c. Stimulating intellectual functioning by discussing new topics with the patient d. Promoting the use of the patient's sense of humor by telling jokes or riddles

ANS: A Patients with cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a step-by-step 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 lose their sense of humor and find jokes and riddles meaningless.

Which outcome for the nursing diagnosis of Risk for injury is appropriate for both a hospitalized patient with delirium who misinterprets reality and a patient with dementia who wanders about the home? a. The patient will remain safe in the present environment. b. The patient will participate actively in self-care. c. The patient will acknowledge reality. d. The patient will communicate confusion.

ANS: A Safety maintenance is the desired outcome of the nursing diagnosis. The other outcomes are not directly related to the stated nursing diagnosis and may or may not be realistic for the patients mentioned because so little is known of their conditions.

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

ANS: A The desired overall outcome is that the delirious patient will return to the level of functioning held before the development of delirium. An outcome of 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.

An older adult with moderate-stage 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 family member to the bathroom hourly. c. Place the family member in disposable diapers. d. Make sure the family member does not eat nonfood items.

ANS: A The patient with moderate Alzheimer's disease 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 diapers is more appropriate as a later stage intervention. It is probably unnecessary at this point. Making sure the patient does not eat nonfood items will be more relevant when the patient demonstrates hyperorality.

Consider these problems: apolipoprotein E (apoE) malfunction, neuritic plaques, neurofibrillary tangles, granulovascular degeneration, and brain atrophy. Which condition corresponds to this group? a. Alzheimer's disease b. AIDS-related dementia c. Wernicke's encephalopathy d. Central anticholinergic syndrome

ANS: A The problems are all aspects of the pathophysiology of Alzheimer's disease.

For planning purposes, a nurse should anticipate that which symptoms of Alzheimer's disease will become apparent as the disease progresses from moderate to severe to late stage? (More than one answer is correct.) a. Agraphia b. Hyperorality c. Hypermetamorphosis d. Improvement of memory e. Fine motor tremors

ANS: A, B, C The memories of patients with Alzheimer's disease are expected to continue to deteriorate. These patients will demonstrate the inability to read or write (agraphia), the need to put everything into the mouth (hyperorality), and the need to touch everything (hypermetamorphosis). Fine motor tremors are associated with alcohol withdrawal delirium, not dementia. The memory will deteriorate.

A patient with Alzheimer's disease has a dressing and grooming self-care deficit. What are the appropriate interventions to include in the patient's nursing care plan? (More than one answer is correct.) a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patient's name and name of the item. c. Provide necessary items and expect the patient to proceed independently. d. Administer anxiolytic medication before bathing and dressing. e. If the patient resists, use distraction and then try again after a short interval. f. If the patient moves too slowly to accomplish the task, the staff should perform it.

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 expecting 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. Patients should be allowed to perform all tasks within their capabilities, even if they perform the task slowly.

During morning care, a nursing assistant asks a patient 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 is the 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.

An older adult drove from home to a nearby store but was unable to remember how to get home and could not state an address. The person's mood was labile. When police took the person home, the spouse reported frequent wandering into neighbors' homes. Alzheimer's disease was diagnosed on further evaluation. Which stage of Alzheimer's disease is evident? a. 1 (mild) b. 2 (moderate) c. 3 (moderate to severe) d. 4 (late)

ANS: B In stage 2 (moderate), deterioration is evident. Memory loss may include the inability to remember addresses or the date. Mood is labile. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. Hygiene may begin to deteriorate. Stage 3 (moderate to severe) finds the individual unable to identify familiar objects or people and needing direction for the simplest of tasks. In stage 4 (late) the ability to talk and walk are eventually lost and stupor evolves.

Select the accurate information a nurse can share with a patient's family regarding risks for developing Alzheimer's disease. a. "Put aside your worries and make the most of the years you have. You will be symptom free until late in life." b. "Statistics show that relatives of people with Alzheimer's disease are predisposed to the disease, but the risk is not universal." c. "You might wish to have genetic testing, because the APOE gene analysis can predict development of late-onset symptoms." d. "Join a health club. There is clear research that shows regular exercise can significantly lower the risk."

ANS: B Little is known of the genetic and nongenetic risk factors for Alzheimer's disease. Even though relatives of patients with Alzheimer's disease are more likely to develop the disease than the general population, no etiological hypotheses have been proven. It may not be true that patients will be symptom free until late in life. It is not true that APOE gene analysis can predict development of late-onset symptoms. It has not been conclusively proven that regular exercise can lower the risk of developing Alzheimer's disease.

A patient with stage 1 Alzheimer's disease is described by the spouse as having lost energy and preferring to stay home rather than attend community activities. The spouse does the grocery shopping because the patient cannot remember what to buy and gets lost in the store. Which nursing diagnosis can be established at this time? a. Risk for injury b. Impaired memory c. Self-care deficit d. Caregiver role strain

ANS: B Memory impairment is present. Data are not present to suggest the other diagnoses.

Which remark by a family member of a patient with dementia demonstrates that psychoeducation regarding medication was effective? "We understand that medications: a. inhibiting the action of dopamine will restore short-term memory." b. inhibiting acetylcholine breakdown may slow the progression of the disease." c. affecting glutamate receptors will provide a cure for late-stage dementia." d. offer no positive effects on cognitive performance."

ANS: B Tacrine, donepezil, rivastigmine, and galantamine act by increasing the brain's supply of acetylcholine, a neurotransmitter deficient in people with Alzheimer's disease. These drugs improve functioning and slow the progress of the disease in 20% to 50% of patients. They do not provide a cure. Memantine affects N-methyl-D-aspartate receptors and has been shown to provide significant benefits when administered with donepezil. Medications affecting dopamine action or glutamate receptors are not indicated in treatment of Alzheimer's disease. It is not true that medications offer no positive effects on cognitive performance.

Consider these health problems: Lewy body disease, Pick's disease, and Korsakoff's syndrome. Which term unifies these problems? a. Intoxication b. Dementia c. Delirium d. Amnesia

ANS: B The listed health problems are all forms of dementia.

What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Bathing/hygiene self-care deficit related to altered cerebral function, as evidenced by confusion and inability to perform personal hygiene tasks b. Risk for injury related to altered cerebral function, misperception of the environment, and unsteady gait 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 hiding from hallucinated dog and asking nurse to remove hallucinated bugs from legs

ANS: B 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; when the patient exercises poor judgment; and when the patient's sensorium is clouded. The other diagnoses are concerns, but are lower priorities.

When a nurse receives information that a patient with delirium is being hospitalized, the nurse would expect to document which assessment findings? (More than one answer is correct.) a. Lack of impairment in level of consciousness b. Disorientation to place and time c. Wandering attention d. Perceptual disturbances e. Self-care competence f. Stable autonomic signs

ANS: B, C, D 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. Illusions and hallucinations are commonly experienced by patients with delirium. Fluctuating levels of consciousness are expected, self-care deficits are usually noted, and autonomic signs, tachycardia, sweating, flushing, dilated pupils, and elevated blood pressure are often present.

What is an important facet of nursing care for a patient with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Avoidance of physical contact b. Application of wrist and ankle restraints c. Careful observation and supervision d. A high level of sensory stimulation

ANS: C Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient will remain safe and free from injury while hospitalized. Physical contact during caregiving cannot be avoided, restraint is a last resort, and sensory stimulation should be reduced.

An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful? a. Placing large clocks and calendars on the wall b. Placing personally meaningful objects in view c. Wearing glasses and hearing aids d. Keeping the room brightly lit constantly

ANS: C Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects may not be noticed. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations.

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

ANS: C 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.

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. Frequently repeat the reorientation strategies. c. Use validating techniques when communicating. d. Place large clocks and calendars strategically.

ANS: C 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.

Two patients in a residential care facility have Alzheimer's disease. One shouts to the other, "Move along, you're blocking the road. I'll take a stick to you." The other patient turns, shakes a fist, and shouts, "I know what you're up to; 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.

Which intervention is appropriate to use for patients with either delirium or dementia? a. Speaking in a loud, firm voice b. Touching the patient before speaking c. Reintroducing the health care worker at each contact d. For aggression, using physical restraint in lieu of medication

ANS: C Short-term memory is often impaired in patients with delirium and dementia. Reorientation to staff is often necessary with each contact to minimize misperceptions, reduce anxiety level, and secure cooperation. Loud voices may be frightening or sound angry. Speaking before touching prevents the patient from feeling threatened. Physical restraint is not appropriate; the least restrictive measure should be used.

A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, "The bugs are crawling on my legs! Get them off!" The nurse assesses this behavior as indicating that the patient is experiencing which problem? 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 coincides with 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.

A patient with marked cognitive impairment is combative and difficult to manage. The patient pulled out a nasogastric tube, intravenous line, and indwelling urinary catheter. The patient also climbed out of bed over the side rails. What can the nurse anticipate that the health care provider will prescribe? a. A small dose of a selective serotonin reuptake inhibitor b. A large dose of a benzodiazepine c. A maintenance dose of buspirone d. A small dose of a high-potency antipsychotic.

ANS: D Aggressive behavior can be safely managed by antipsychotic medication. Initial dosing should be small and raised cautiously until behavior is controlled. Selective serotonin reuptake inhibitors are not indicated for aggressive behavior. If a benzodiazepine is used, the initial dose should be low. Buspirone is not effective if given on an as-needed basis. It is administered in small divided doses daily to control agitation.

A patient with stage 2 Alzheimer's disease calls the police saying, "An intruder is in my home." Police investigate and find that the patient misinterpreted the reflection in the mirror as an intruder. This phenomenon can be assessed as: 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.

A nurse administers medications to four patients with Alzheimer's disease. Which medication would be expected to antagonize NMDA channels rather than cholinesterase? a. Donepezil (Aricept) b. Rivastigmine (Exelon) c. Galantamine (Razadyne/Reminyl) d. Memantine (Namenda)

ANS: D 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.

An older adult who is stopped by police for driving through a red light says, "I've lived here my whole life. There's no light there." The person was unable to state a home address. The officer took the person home, where the spouse stated that the individual "wanders around the neighborhood, sometimes taking tools from people's garages." On evaluation at a medical facility, the person was diagnosed with Alzheimer's disease. What cardinal sign of Alzheimer's disease was evident? a. Aphasia b. Apraxia c. Agnosia d. Memory impairment

ANS: D Of the cardinal signs of Alzheimer's disease, the patient is presently demonstrating only mnemonic disturbance, or memory loss. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. Agnosia refers to the loss of sensory ability to recognize objects.

Which action can the nurse advise a family to take in the home to enhance safety for a patient with Alzheimer's disease who wanders at night? a. Place throw rugs on tile or wooden floors. b. Obtain a bed with side rails. c. Encourage daytime napping. d. Place locks at the tops of doors.

ANS: D 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. All throw rugs should be removed to prevent falls. The patient will try to climb over side rails, increasing the risk for injury and falls. Day napping should be discouraged with the hope that the patient will sleep during the night.

A patient with dementia no longer recognizes family members. The family asks how long it will be before their family member recognizes them when they visit. What is the nurse's best reply? a. "I think that is a question the health care provider will need to answer." b. "Your family member will never again be able to identify you." c. "One never knows. Consciousness fluctuates in patients 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. The first two responses close communication. The nurse should take the opportunity to foster communication. It is not true that consciousness fluctuates in patients with dementia.

A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get the bugs off me." What is the nurse's best response? a. "There are no bugs on your legs. Your imagination is playing tricks on you." b. "Try to relax. The crawling sensation will go away sooner if you can relax." c. "Don't worry, I will have someone stay here and brush away the bugs for you." d. "I don't see any bugs, but I know you are frightened so 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.