Toughy Chapter 25 Care for Neurological Disorders

Which intervention to manage wandering in clients in a long-term care facility should be implemented? (Select all that apply.) a. Camouflaging doorways b. Close observation to identify the person's individual patterns c. Engaging the person in social interactions d. Using physical restraints to prevent wandering to maintain safety e. Providing enclosed pathways for walking

a. Camouflaging doorways b. Close observation to identify the person's individual patterns c. Engaging the person in social interactions e. Providing enclosed pathways for walking

The nurse working in a long-term care facility completes her morning assessment on a new postoperative patient and notes a change in cognitive status from the previous day? The nurse recognizes which of the following as a precipitating factor for delirium? (Select all that apply.) a. Major medical treatment b. Poor sleep habits c. Admission to long-term care d. Pharmacological agents

a. Major medical treatment c. Admission to long-term care d. Pharmacological agents

Which assessment parameter should the nurse use to differentiate between delirium and depression in an older adult? a. Orientation b. Activity c. Course over the morning hours d. Psychomotor activity

a. Orientation

An older woman has a wound infection 5 days after a below-the-knee amputation brought about by diabetes mellitus. Which of the following is the nurse's priority intervention to prevent cognitive dysfunction and postoperative complications in this older adult? a. Remove invasive devices as soon as possible. b. Minimize the administration of opioid analgesics. c. Allow for self-care and independent activities. d. Administer short-acting benzodiazepines as needed.

a. Remove invasive devices as soon as possible.

When differentiating the characteristics of depression, delirium, and dementia, the nurse recognized which of the following as an indicator of delirium? a. Sudden onset b. Recent loss c. Insidious d. Life change

a. Sudden onset

At 10 PM, an older male resident attempts to climb over the bedrails. Which intervention should the nurse implement first? a. Talk to the resident about his behavior. b. Call the physician, and ask for a sedative. c. Apply a vest restraint on the resident. d. Get a companion to keep him in the bed.

a. Talk to the resident about his behavior.

An older client diagnosed with dementia resides with his daughter. When the home care nurse visits, the daughter tearfully tells the nurse that her father scratched her hand and cursed at her when she was attempting to feed him. She states, "I don't know why he hates me and wants to hurt me. I try so hard to take good care of him. I love him." How will the nurse respond to the client's daughter? a. "Let's think about what you may have done to anger your father." b. "Let's try to figure out what your father was trying to say with his behavior." c. "Scratching is usually a sign of untreated pain. Do you think your father is in pain?" d. "Maybe you should consider having a home health provide your father's physical care."

b. "Let's try to figure out what your father was trying to say with his behavior."

Which of the following should the nurse use to assess a nonverbal older adult for delirium? a. Cranial nerves (CNs) XI and XII b. Confusion Assessment Method (CAM) c. MMSE-2 d. Controlled Word Association Test

b. Confusion Assessment Method (CAM)

Which information will the nurse manager include when discussing the major differentiation between delirium and dementia with novice nurses? (Select all that apply.) a. The delirious client learns to make up answers to hide their confusion. b. Delirium requires increased monitoring at night. c. The client diagnosed with dementia generally looks frightened. d. Dementia results in a steady decline in cognitive abilities. e. Delirium is characterized by fluctuations in alertness.

b. Delirium requires increased monitoring at night. d. Dementia results in a steady decline in cognitive abilities. e. Delirium is characterized by fluctuations in alertness.

An older woman is recovering from a bowel resection in the intensive care unit (ICU) but remains intubated and on a mechanical ventilator. Which of the following should the nurse implement to help prevent delirium in this woman? a. Assess cognition with the Mini-Mental State Examination, 2nd edition (MMSE-2). b. Provide uninterrupted periods of rest and sleep. c. Maintain adequate sedation and pain management. d. Cover the patient's eyes with protective ophthalmic ointment.

b. Provide uninterrupted periods of rest and sleep.

An older woman with dementia exhibits new behaviors including crying and repeatedly verbalizing the same phrase; furthermore, the behavior has increased over 2 days. Which intervention should the nurse implement in response to this behavior? a. Tell her you will remember what she says if she stops crying. b. Attribute these findings to a deterioration in cognitive function. c. Check the medication administration record for missed doses. d. Present probing questions to the patient about her behavior.

c. Check the medication administration record for missed doses.

A definitive diagnosis of Alzheimer's disease (AD) can be made by detecting or using which one of the following methods? a. Clinical observation of dementia b. Inability to speak with relevance c. Development of neurofibrillary tangles d. Computed tomography (CT) scan

c. Development of neurofibrillary tangles

The nurse recognizes which of the following displays may indicate hyperactive delirium? a. Lethargy b. Withdrawn behavior c. Nonpurposeful repetitive movements d. Decreased psychoactive activity

c. Nonpurposeful repetitive movements

Which of the following approaches to hygienic care is beneficial for a patient with dementia? a. Schedule the patient's full shower at 7 AM, three mornings every week. b. Have a team give the bath with each member washing a different body area. c. Wash the perineal region first to remove potentially infectious material. d. Explain each step as you go and keep the patient covered as much as possible while bathing.

d. Explain each step as you go and keep the patient covered as much as possible while bathing.

Which of the following statements is true about cognitive impairments in older adults? a. Loss or interruption of sleep can lead to delirium. b. Confusion is a normal and unavoidable consequence of aging. c. Older patients who are agitated often have a lower cognitive status than those who are quietly sitting. d. The Mini-Mental State Exam-2 (MMSE-2) should be administered on admission to detect delirium.

d. The Mini-Mental State Exam-2 (MMSE-2) should be administered on admission to detect delirium.