Alzheimer's Disease, Dementia, and Delirium NCLEX Style Questions

The nurse's initial action for a patient with moderate dementia who develops increased restlessness and agitation should be to a. reorient the patient to time, place, and person. b. administer a PRN dose of lorazepam (Ativan). c. assess for factors that might be causing discomfort. d. assign unlicensed assistive personnel (UAP) to stay in the patient's room.

ANS: C Increased motor activity in a patient with dementia is frequently the patient's only way of responding to factors like pain, so the nurse's initial action should be to assess the patient for any precipitating factors. Administration of sedative drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia. Assigning UAP to stay with the patient may also be necessary, but any physical changes that may be causing the agitation should be addressed first.

A 68-year-old patient is diagnosed with moderate dementia after multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. difficulty eating and swallowing. c. loss of recent and long-term memory. d. fluctuating ability to perform simple tasks.

ANS: C Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient's ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia.

A 71-year-old patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care? a. Reorient the patient several times daily. b. Have the family bring in familiar items. c. Place the patient in a room close to the nurses' station. d. Ask the patient why the wandering episodes have occurred.

ANS: C Patients at risk for problems with safety require close supervision. Placing the patient near the nurse's station will allow nursing staff to observe the patient more closely. The use of "why" questions can be frustrating for patients with AD because they are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patient's short-term memory loss, reorientation will not help prevent wandering behavior. Because the patient had wandering behavior at home, familiar objects will not prevent wandering.

A patient is being evaluated for Alzheimer's disease (AD). The nurse explains to the patient's adult children that a. the most important risk factor for AD is a family history of the disorder. b. new drugs have been shown to reverse AD dramatically in some patients. c. a diagnosis of AD is made only after other causes of dementia are ruled out. d. the presence of brain atrophy detected by magnetic resonance imaging (MRI) will confirm the diagnosis of AD.

ANS: C The diagnosis of AD is usually one of exclusion. Age is the most important risk factor for development of AD

A patient is being evaluated for Alzheimer's disease (AD). The nurse explains to the patient's adult children that a. the most important risk factor for AD is a family history of the disorder. b. new drugs have been shown to reverse AD dramatically in some patients. c. a diagnosis of AD is made only after other causes of dementia are ruled out. d. the presence of brain atrophy detected by magnetic resonance imaging (MRI) will confirm the diagnosis of AD.

ANS: C The diagnosis of AD is usually one of exclusion. Age is the most important risk factor for development of AD. Drugs may slow the deterioration but do not reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in other diseases as well and does not confirm a diagnosis of AD.

Which hospitalized patient will the nurse assign to the room closest to the nurses' station? a. Patient with Alzheimer's disease who has long-term memory deficit b. Patient with vascular dementia who takes medications for depression c. Patient with new-onset confusion, restlessness, and irritability after surgery d. Patient with dementia who has an abnormal Mini-Mental State Examination

ANS: C This patient's history and clinical manifestations are consistent with delirium. The patient is at risk for safety problems and should be placed near the nurses' station for ongoing observation. The other patients have chronic symptoms that are consistent with their diagnoses but are not at immediate risk for safety issues.

A 71-year-old patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care? a. Reorient the patient several times daily. b. Have the family bring in familiar items. c. Place the patient in a room close to the nurses' station. d. Ask the patient why the wandering episodes have occurred.

ANS: C-Place the patient in a room close to the nurses' station. Patients at risk for problems with safety require close supervision. Placing the patient near the nurse's station will allow nursing staff to observe the patient more closely

After change-of-shift report on the Alzheimer's disease/dementia unit, which patient will the nurse assess first? a. Patient who has not had a bowel movement for 5 days b. Patient who has a stage II pressure ulcer on the coccyx c. Patient who is refusing to take the prescribed medications d. Patient who developed a new cough after eating breakfast

ANS: D A new cough after a meal in a patient with dementia suggests possible aspiration and the patient should be assessed immediately. The other patients also require assessment and intervention, but not as urgently as a patient with possible aspiration or pneumonia.

The nurse is concerned about a postoperative patient's risk for injury during an episode of delirium. The most appropriate action by the nurse is to a. secure the patient in bed using a soft chest restraint. b. ask the health care provider to order an antipsychotic drug. c. instruct family members to remain with the patient and prevent injury. d. assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation.

ANS: D The priority goal is to protect the patient from harm. Having a UAP stay with the patient will ensure the patient's safety. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have many side effects. Restraints are not recommended because they can increase the patient's agitation and disorientation.

6. When administering a mental status examination to a patient, the nurse suspects depression when the patient responds with a. "I don't know." b. "Is that the right answer?" c. "Wait, let me think about that." d. "Who are those people over there?

a. "I don't know." Answers such as "I don't know" are more typical of depression. The response "Who are those people over there?" is more typical of the distraction seen in a patient with delirium. The remaining two answers are more typical of a patient with dementia.

11. A patient with mild dementia has a new prescription for donepezil (Aricept). Which nursing action will be most effective in ensuring compliance with the medication? a. Having the patient's spouse administer the medication b. Setting the medications up weekly in a medication box c. Calling the patient daily with a reminder to take the medication d. Posting reminders to take the medications in the patient's house

a. Having the patient's spouse administer the medication Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the drug. The other nursing actions will not be as effective in ensuring that the patient takes the medications.

13. When assessing a patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility, the nurse learns that the patient has had several episodes of wandering away from home. Which nursing action will the nurse include in the plan of care? a. Place the patient in a room close to the nurses' station. b. Ask the patient why the wandering episodes have occurred. c. Have the family bring in familiar items from the patient's home. d. Reorient the patient to the new living situation several times daily.

a. Place the patient in a room close to the nurses' station. Patients at risk for problems with safety require close supervision. Placing the patient near the nurse's station will allow nursing staff to observe the patient more closely. The use of "why" questions is frustrating for patients with AD because they are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patient's short-term memory loss, reorientation will not help prevent wandering behavior. Because the patient had wandering behavior at home, familiar objects will not prevent wandering.

1. A patient who is hospitalized with pneumonia is disoriented and confused 2 days after admission. Which information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patient's speech is fragmented and incoherent. c. The patient is disoriented to place and time but oriented to person. d. The patient has a history of increasing confusion over several years.

a. The patient was oriented and alert when admitted. The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia.

The family caregiver for a patient with AD expresses an inability to make decisions, concentrate, or sleep. The nurse determines what about the caregiver? a. The caregiver is also developing signs of AD. b. The caregiver is manifesting symptoms of caregiver role strain. c. The caregiver needs a period of respite from care of the patient. d. The caregiver should ask other family members to participate in the patient's care.

b. Family caregiver role strain is characterized by such symptoms of stress as the inability to sleep, make decisions, or concentrate. It is frequently seen in family members who are responsible for the care of the patient with AD. Assessment of the caregiver may reveal a need for assistance to increase coping skills, effectively use community resources, or maintain social relationships. Eventually the demands on a caregiver exceed the resources and the person with AD may be placed in an institutional setting.

Bridge to NCLEX questions: Creutzfeldt-Jakob disease is characterized by a. remissions and exacerbations over many years. b. memory impairment, muscle jerks, and blindness. c. parkinsonian symptoms, including muscle rigidity and tremors at rest. d. increased intracranial pressure secondary to decreased CSF drainage.

b. memory impairment, muscle jerks, and blindness. Rationale: Creutzfeldt-Jakob disease (CJD) is a fatal brain disorder caused by a prion protein. The earliest symptom of the disease may be memory impairment and behavioral changes. The disease progresses rapidly, with mental deterioration, involuntary movements (i.e., muscle jerks), weakness in the limbs, blindness, and eventually coma

A 72-year-old female patient is brought to the clinic by the patient's spouse, who reports that she is unable to solve common problems around the house. To obtain information about the patient's current mental status, which question should the nurse ask the patient? a. "Are you sad?" b. "How is your self-image?" c. "Where were you were born?" d. "What did you eat for breakfast?"

ANS: D-"What did you eat for breakfast?" This question tests the patient's short-term memory, which is decreased in the mild stage of Alzheimer's disease or dementia

A 72-year-old female patient is brought to the clinic by the patient's spouse, who reports that she is unable to solve common problems around the house. To obtain information about the patient's current mental status, which question should the nurse ask the patient? a. "Are you sad?" b. "How is your self-image?" c. "Where were you were born?" d. "What did you eat for breakfast?"

ANS: D This question tests the patient's short-term memory, which is decreased in the mild stage of Alzheimer's disease or dementia. Asking the patient about her birthplace tests for remote memory, which is intact in the early stages. Questions about the patient's emotions and self-image are helpful in assessing emotional status, but they are not as helpful in assessing mental state

7. A 72-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. difficulty eating and swallowing. c. variable ability to perform simple tasks. d. loss of both recent and long-term memory.

d. loss of both recent and long-term memory. Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient's ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia.

A 68-year-old patient is diagnosed with moderate dementia after multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. difficulty eating and swallowing. c. loss of recent and long-term memory. d. fluctuating ability to perform simple tasks.

ANS: C Loss of both recent and long-term memory is characteristic of moderate dementia

NCLEX review questions: The patient has been diagnosed with the mild cognitive impairment stage of Alzheimer's disease. What nursing interventions should the nurse expect to use with this patient? A) Treat disruptive behavior with antipsychotic drugs. B) Use a calendar and family pictures as memory aids. C) Use a writing board to communicate with the patient. D) Use a wander guard mechanism to keep the patient in the area.

B) Use a calendar and family pictures as memory aids. Rationale: The patient with mild cognitive impairment will have problems with memory, language, or another essential cognitive function that is severe enough to be noticeable to others but does not interfere with activities of daily living. A calendar and family pictures for memory aids will help this patient. This patient should not yet have disruptive behavior or get lost easily. Using a writing board will not help this patient with communication.

Pre-test practice questions: The home care nurse is visiting patients in the community. Which patient is exhibiting an early warning sign of Alzheimer's disease? A) A 65-year-old male does not recognize his family members and close friends. B) A 59-year-old female misplaces her purse and jokes about having memory loss. C) A 79-year-old male is incontinent and not able to perform hygiene independently. D) A 72-year-old female is unable to locate the address where she has lived for 10 years.

D) A 72-year-old female is unable to locate the address where she has lived for 10 years. Rationale: An early warning sign of Alzheimer's disease is disorientation to time and place such as geographic disorientation. Occasionally misplacing items and joking about memory loss are examples of normal forgetfulness. Impaired ability to recognize family and close friends is a clinical manifestation of middle or moderate dementia (or Alzheimer's disease). Incontinence and inability to perform self-care activities are clinical manifestations of severe or late dementia (or Alzheimer's disease).

NCLEX review questions: Which patient may face the greatest risk of developing delirium? A) A patient with fibromyalgia whose chronic pain has recently worsened B) A patient with a fracture who has spent the night in the emergency department C) An older patient whose recent computed tomography (CT) shows brain atrophy D) An older patient who takes multiple medications to treat various health problems

D) An older patient who takes multiple medications to treat various health problems Rationale: Polypharmacy is implicated in many cases of delirium, and this phenomenon is especially common among older adults. Brain atrophy, if associated with cognitive changes, is indicative of dementia. Alterations in sleep and environment, as well as pain, may cause delirium, but this is less of a risk than in an older adult who takes multiple medications.

3. When administering a mental status examination to a patient with delirium, the nurse should a. medicate the patient first to reduce any anxiety. b. give the examination when the patient is well-rested. c. reorient the patient as needed during the examination. d. choose a place without distracting environmental stimuli.

d. choose a place without distracting environmental stimuli. Because overstimulation by environmental factors can distract the patient from the task of answering the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient's delirium.

NCLEX review questions: A 59-year-old female patient, who has frontotemporal lobar degeneration, has difficulty with verbal expression. One day she walks out of the house and goes to the gas station to get a soda but does not understand that she needs to pay for it. What is the best thing the nurse can suggest to this patient's husband to keep the patient safe during the day while the husband is at work? A) Assisted living B) Adult day care C) Advance directives D) Monitor for behavioral changes

B) Adult day care Rationale: To keep this patient safe during the day while the husband is at work, an adult day care facility would be the best choice. This patient would not need assisted living. Advance directives are important but are not related to her safety. Monitoring for behavioral changes will not keep her safe during the day.

19. Delegation Decision: The RN in charge at a long-term care facility could delegate which activities to unlicensed assistive personnel (UAP) (select all that apply)? a. Assist the patient with eating. b. Provide personal hygiene and skin care. c. Check the environment for safety hazards. d. Assist the patient to the bathroom at regular intervals. e. Monitor for skin breakdown and swallowing difficulties.

19. a, b, d. All caregivers are responsible for the patient's safety. Basic care activities, such as those associated with personal hygiene and activities of daily living (ADLs) can be delegated to unlicensed assistive personnel (UAP). The RN will perform ongoing assessments and develop and revise the plan of care as needed. The RN will assess the patient's safety risk factors, provide education, and make referrals. The licensed practical nurse (LPN) could check the patient's environment for potential safety hazards.

Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia? a. Setting the medications up monthly in a medication box b. Having the patient's family member administer the medication c. Posting reminders to take the medications in the patient's house d. Calling the patient weekly with a reminder to take the medication

ANS: B Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the drug. The other nursing actions will not be as effective in ensuring that the patient takes the medications.

12. A patient with AD in a long-term care facility is wandering the halls very agitated, asking for her "mommy" and crying. What is the best response by the nurse? a. Ask the patient, "Why are you behaving this way?" b. Tell the patient, "Let's go get a snack in the kitchen." c. Ask the patient, "Wouldn't you like to lie down now?" d. Tell the patient, "Just take some deep breaths and calm down."

12. b. Patients with moderate to severe AD frequently become agitated but because their short-term memory loss is so pronounced, distraction is a very good way to calm them. "Why" questions are upsetting to them because they don't know the answer and they cannot respond to normal relaxation techniques.

11. What N-methyl-d-aspartate (NMDA) receptor antagonist is frequently used for a patient with AD who is experiencing decreased memory and cognition? a. Trazodone (Desyrel) b. Olanzapine (Zyprexa) c. Rivastigmine (Exelon) d. Memantine (Namenda)

11. d. Memantine (Namenda) is the N-methyl-d-aspartate (NMDA) receptor antagonist frequently used for AD patients with decreased memory and cognition. Trazodone (Desyrel) is an atypical antidepressant that may help with sleep problems. Olanzapine (Zyprexa) is an antipsychotic medication used for behavior management. Rivastigmine (Exelon) is a cholinesterase inhibitor used for decreased memory and cognition.

A patient who has severe Alzheimer's disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care? a. Encourage the patient to discuss events from the past. b. Maintain a consistent daily routine for the patient's care. c. Reorient the patient to the date and time every 2 to 3 hours. d. Provide the patient with current newspapers and magazines.

ANS: B Providing a consistent routine will decrease anxiety and confusion for the patient. Reorientation to time and place will not be helpful to the patient with severe AD, and the patient will not be able to read. The patient with severe AD will probably not be able to remember events from the past.

Which action will help the nurse determine whether a new patient's confusion is caused by dementia or delirium? a. Administer the Mini-Mental Status Exam. b. Use the Confusion Assessment Method tool. c. Determine whether there is a family history of dementia. d. Obtain a list of the medications that the patient usually takes.

ANS: B The Confusion Assessment Method tool has been extensively tested in assessing delirium.

9. What is one focus of collaborative care of patients with AD? a. Replacement of deficient acetylcholine in the brain b. Drug therapy for cognitive problems and undesirable behaviors c. The use of memory-enhancing techniques to delay disease progression d. Prevention of other chronic diseases that hasten the progression of AD

9. b. Because there is no cure for AD, collaborative management is aimed at controlling the decline in cognition, controlling the undesirable manifestations that the patient may exhibit, and providing support for the family caregiver. Anticholinesterase agents help to increase acetylcholine (ACh) in the brain but a variety of other drugs are also used to control behavior. Memoryenhancing techniques have little or no effect in patients with AD, especially as the disease progresses. Patients with AD have limited ability to communicate health symptoms and problems, leading to a lack of professional attention for acute and other chronic illnesses.

2. Which statement accurately describes dementia? a. Overproduction of β-amyloid protein causes all dementias. b. Dementia resulting from neurodegenerative causes can be prevented. c. Dementia caused by hepatic or renal encephalopathy cannot be reversed. d. Vascular dementia can be diagnosed by brain lesions identified with neuroimaging.

2. d. The diagnosis of vascular dementia can be aided by neuroimaging studies showing vascular brain lesions along with exclusion of other causes of dementia. Overproduction of β-amyloid protein contributes to Alzheimer's disease (AD). Vascular dementia can be prevented or slowed by treating underlying diseases (e.g., diabetes mellitus, cardiovascular disease). Dementia caused by hepatic or renal encephalopathy potentially can be reversed.

21. A 68-year-old man is admitted to the emergency department with multiple blunt trauma following a one-vehicle car accident. He is restless; disoriented to person, place, and time; and agitated. He resists attempts at examination and calls out the name "Janice." Why should the nurse suspect delirium rather than dementia in this patient? a. The fact that he wouldn't have been allowed to drive if he had dementia b. His hyperactive behavior, which differentiates his condition from the hypoactive behavior of dementia c. The report of emergency personnel that he was noncommunicative when they arrived at the accident scene d. The report of his family that although he has heart disease and is "very hard of hearing," this behavior is unlike him

21. d. Delirium is an acute problem that usually has a rapid onset in response to a precipitating event, especially when the patient has underlying health problems, such as heart disease and sensory limitations. In the absence of prior cognitive impairment, a sudden onset of confusion, disorientation, and agitation is usually delirium. Delirium may manifest with both hypoactive and hyperactive symptoms.

3. A patient with Alzheimer's disease (AD) dementia has manifestations of depression. The nurse knows that treatment of the patient with antidepressants will most likely do what? a. Improve cognitive function b. Not alter the course of either condition c. Cause interactions with the drugs used to treat the dementia d. Be contraindicated because of the central nervous system (CNS)-depressant effect of antidepressants

3. a. Depression is often associated with AD, especially early in the disease when the patient has awareness of the diagnosis and the progression of the disease. When dementia and depression occur together, intellectual deterioration may be more extreme. Depression is treatable and use of antidepressants often improves cognitive function.

4. For what purpose would the nurse use the Mini-Mental State Examination to evaluate a patient with cognitive impairment? a. It is a good tool to determine the etiology of dementia. b. It is a good tool to evaluate mood and thought processes. c. It can help to document the degree of cognitive impairment in delirium and dementia. d. It is useful for initial evaluation of mental status but additional tools are needed to evaluate changes in cognition over time.

4. c. The Mini-Mental State Examination is a tool to document the degree of cognitive impairment and it can be used to determine a baseline from which changes over time can be evaluated. It does not evaluate mood or thought processes but can detect dementia and delirium and differentiate these from psychiatric mental illness. It cannot help to determine etiology.

5. During assessment of a patient with dementia, the nurse determines that the condition is potentially reversible when finding out what about the patient? a. Has long-standing abuse of alcohol b. Has a history of Parkinson's disease c. Recently developed symptoms of hypothyroidism d. Was infected with human immunodeficiency virus (HIV) 10 years ago

5. c. Hypothyroidism can cause dementia but it is a treatable condition if it has not been long standing. The other conditions are causes of irreversible dementia.

Pre-test practice questions: Although he has been told that ginkgo biloba will probably have no effect, a 58-year-old man with early stage Alzheimer's disease insists on taking the herb because he believes it will slow the disease progression. Which statement, if made by the patient to the nurse, indicates understanding about the side effects of ginkgo? A) "Ginkgo may increase the risk of bruising." B) "Ginkgo may cause leg pain while walking." C) "It is not safe to suddenly stop taking ginkgo." D) "Ringing in the ears is a side effect of ginkgo."

A) "Ginkgo may increase the risk of bruising." Rationale: Ginkgo biloba may increase the risk for bruising and bleeding. There are no indications that sudden withdrawal of ginkgo biloba is unsafe. Ginkgo biloba is possibly effective for treating intermittent claudication (leg pain while walking). There is insufficient evidence to indicate that ginkgo biloba is effective in treatment of tinnitus (ringing in the ears).

NCLEX review questions: For which patient should the nurse prioritize an assessment for depression? A) A patient in the early stages of Alzheimer's disease B) A patient who is in the final stages of Alzheimer's disease C) A patient experiencing delirium secondary to dehydration D) A patient who has become delirious following an atypical drug response

A) A patient in the early stages of Alzheimer's disease Rationale: Patients in the early stages of Alzheimer's disease are particularly susceptible to depression, since the patient is acutely aware of his or her cognitive changes and the expected disease trajectory. Delirium is typically a shorter-term health problem that does not typically pose a heightened risk of depression.

Which action will help the nurse determine whether a new patient's confusion is caused by dementia or delirium? a. Administer the Mini-Mental Status Exam. b. Use the Confusion Assessment Method tool. c. Determine whether there is a family history of dementia. d. Obtain a list of the medications that the patient usually takes.

ANS: B The Confusion Assessment Method tool has been extensively tested in assessing delirium. The other actions will be helpful in determining cognitive function or risk factors for dementia or delirium, but they will not be useful in differentiating between dementia and delirium.

NCLEX review questions: Benzodiazepines are indicated in the treatment of cases of delirium that have which cause? A) Polypharmacy B) Cerebral hypoxia C) Alcohol withdrawal D) Electrolyte imbalances

C) Alcohol withdrawal Rationale: Benzodiazepines can be used to treat delirium associated with sedative and alcohol withdrawal. However, these drugs may worsen delirium caused by other factors and must be used cautiously. Polypharmacy, cerebral hypoxia, and electrolyte imbalances are not treated with benzodiazepines.

Bridge to NCLEX questions: Vascular dementia is associated with a. transient ischemic attacks. b. bacterial or viral infection of neuronal tissue. c. cognitive changes secondary to cerebral ischemia. d. abrupt changes in cognitive function that are irreversible.

c. cognitive changes secondary to cerebral ischemia. Rationale: Vascular dementia is the loss of cognitive function that results from ischemic, ischemic-hypoxic, or hemorrhagic brain lesions caused by cardiovascular disease. In this type of dementia, narrowing and blocking of arteries that supply the brain causes a decrease in blood supply.

4. To protect a patient from injury during an episode of delirium, the most appropriate action by the nurse is to a. secure the patient in bed using a soft chest restraint. b. ask the health care provider about ordering an antipsychotic drug. c. instruct family members to remain with the patient and prevent injury. d. assign a nursing assistant to stay with the patient and offer frequent reorientation.

d. assign a nursing assistant to stay with the patient and offer frequent reorientation. The priority goal is to protect the patient from harm, and a staff member will be most experienced in providing safe care. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have multiple side effects. Restraints are sometimes used but tend to increase agitation and disorientation.

Bridge to NCLEX questions: Dementia is defined as a a. syndrome that results only in memory loss. b. disease associated with abrupt changes in behavior. c. disease that is always due to reduced blood flow to the brain. d. syndrome characterized by cognitive dysfunction and loss of memory.

d. syndrome characterized by cognitive dysfunction and loss of memory. Rationale: Dementia is a syndrome characterized by dysfunction in or loss of memory, orientation, attention, language, judgment, and reasoning. Personality changes and behavioral problems such as agitation, delusions, and hallucinations may result.

17. The wife of a man with moderate AD has a nursing diagnosis of social isolation related to diminishing social relationships and behavioral problems of the patient with AD. What is a nursing intervention that would be appropriate to provide respite care and allow the wife to have satisfactory contact with significant others? a. Help the wife to arrange for adult day care for the patient. b. Encourage permanent placement of the patient in the Alzheimer's unit of a long-term care facility. c. Refer the wife to a home health agency to arrange daily home nursing visits to assist with the patient's care. d. Arrange for hospitalization of the patient for 3 or 4 days so that the wife can visit out-of-town friends and relatives.

17. a. Adult day care is an option to provide respite for caregivers and a protective environment for the patient during the early and middle stages of AD. There are also in-home respite care providers. The respite from the demands of care allows the caregiver to maintain social contacts, perform normal tasks of living, and be more responsive to the patient's needs. Visits by home health nurses involve the caregiver and cannot provide adequate respite. Institutional placement is not always an acceptable option at earlier stages of AD, nor is hospitalization available for respite care.

18. The health care provider is trying to differentiate the diagnosis of the patient between dementia and dementia with Lewy bodies (DLB). What observations by the nurse support a diagnosis of DLB (select all that apply)? a. Tremors b. Fluctuating cognitive ability c. Disturbed behavior, sleep, and personality d. Symptoms of pneumonia, including congested lung sounds e. Bradykinesia, rigidity, and postural instability without tremor

18. b, e. Dementia with Lewy bodies (DLB) is diagnosed with dementia plus two of the following symptoms: (1) extrapyramidal signs such as bradykinesia, rigidity, and postural instability but not always a tremor, (2) fluctuating cognitive ability, and (3) hallucinations. The extrapyramidal signs plus tremors would more likely indicate Parkinson's disease. Disturbed behavior, sleep, personality, and eventually memory are characteristics of frontotemporal lobe degeneration (FTLD).

NCLEX review questions: Which statement by the wife of a patient with Alzheimer's disease (AD) demonstrates an accurate understanding of her husband's medication regimen? A) "I'm really hoping his medications will slow down his mental losses." B) "We're both holding out hope that this medication will cure his disease." C) "I know that this won't cure him, but we learned that it might prevent a bodily decline while he declines mentally." D) "I learned that if we are vigilant about his medication schedule, he may not experience the physical effects of his disease."

A) "I'm really hoping his medications will slow down his mental losses." Rationale: There is presently no cure for Alzheimer's disease, and drug therapy aims at improving or controlling decline in cognition. Medications do not directly address the physical manifestations of AD.

NCLEX review questions: The nurse who has administered a dose of risperidone (Risperdal) to a patient with delirium should assess for what intended effect of the medication? A) Lying quietly in bed B) Alleviation of depression C) Reduction in blood pressure D) Disappearance of confusion

A) Lying quietly in bed Rationale: Risperidone is an antipsychotic drug that reduces agitation and produces a restful state in patients with delirium. However, it should be used with caution. Antidepressant medications treat depression, and antihypertensive medications treat hypertension. However, there are no medications that will cause confusion to disappear in a patient with delirium.

Bridge to NCLEX questions: A major goal of treatment for the patient with AD is to a. maintain patient safety. b. maintain or increase body weight. c. return to a higher level of self-care. d. enhance functional ability over time.

a. maintain patient safety. Rationale: The overall management goals are that the patient with AD will (1) maintain functional ability for as long as possible, (2) be maintained in a safe environment with a minimum of injuries, (3) have personal care needs met, and (4) have dignity maintained. The nurse should place emphasis on patient safety while planning and providing nursing care.

What manifestations of cognitive impairment are primarily characteristic of delirium (select all that apply)? a. Reduced awareness b. Impaired judgments c. Words difficult to find d. Sleep/wake cycle reversed e. Distorted thinking and perception f. Insidious onset with prolonged duration

a, d, e. Manifestations of delirium include cognitive impairment with reduced awareness, reversed sleep/wake cycle, and distorted thinking and perception. The other options are characteristic of dementia.

12. Which intervention will the nurse include in the plan of care for a patient who has late-stage Alzheimer's disease (AD)? a. Encourage the patient to discuss events from the past. b. Maintain a consistent daily routine for the patient's care. c. Reorient the patient to the date and time every 2 to 3 hours. d. Provide the patient with current newspapers and magazines.

b. Maintain a consistent daily routine for the patient's care. Providing a consistent routine will decrease anxiety and confusion for the patient. In late-stage AD, the patient will not remember events from the past. Reorientation to time and place will not be helpful to the patient with late-stage AD, and the patient will not be able to read.

2. When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse include? a. Provide complete personal hygiene care for the patient. b. Remind the patient frequently about being in the hospital. c. Reposition the patient frequently to avoid skin breakdown. d. Place suction at the bedside to decrease the risk for aspiration.

b. Remind the patient frequently about being in the hospital. The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.

Bridge to NCLEX questions: The early stage of AD is characterized by a. no noticeable change in behavior. b. memory problems and mild confusion. c. increased time spent sleeping or in bed. d. incontinence, agitation, and wandering behavior.

b. memory problems and mild confusion. Rationale: An initial sign of AD is a subtle deterioration in memory.

10. When teaching the children of a patient who is being evaluated for Alzheimer's disease (AD) about the disorder, the nurse explains that a. the most important risk factor for AD is a family history of the disorder. b. new drugs have been shown to reverse AD dramatically in some patients. c. a diagnosis of AD can be made only when other causes of dementia have been ruled out. d. the presence of brain atrophy detected by MRI confirms the diagnosis of AD in patients with dementia.

c. a diagnosis of AD can be made only when other causes of dementia have been ruled out. The diagnosis of AD is one of exclusion. Age is the most important risk factor for development of AD. Drugs can slow the deterioration but do not dramatically reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in other diseases as well and does not confirm an AD diagnosis.

15. A long-term care patient with moderate dementia develops increased restlessness and agitation. The nurse's initial action should be to a. reorient the patient to time, place, and person. b. administer the PRN dose of lorazepam (Ativan). c. assess for factors that might be causing discomfort. d. have a nursing assistant stay with the patient to ensure safety.

c. assess for factors that might be causing discomfort. Increased motor activity in a patient with dementia is frequently the patient's only way of responding to factors like pain, so the nurse's initial action should be to assess the patient for any precipitating factors. Administration of sedative drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia. Assigning a nursing assistant to stay with the patient also may be necessary, but any physical changes that may be causing the agitation should be addressed first.

10. The patient is receiving donepezil (Aricept), lorazepam (Ativan), risperidone (Risperdal), and sertraline (Zoloft) for the management of AD. What benzodiazepine medication is being used to help manage this patient's behavior? a. Sertraline (Zoloft) b. Donepezil (Aricept) c. Lorazepam (Ativan) d. Risperidone (Risperdal)

10. c. Lorazepam (Ativan) is a benzodiazepine used to manage behavior with AD. Sertraline (Zoloft) is a selective serotonin reuptake inhibitor used to treat depression. Donepzil (Aricept) is a cholinesterase inhibitor used for decreased memory and cognition. Risperidone (Risperdal) is an antipsychotic used for behavior management.

23. When caring for a patient in the severe stage of AD, what diversion or distraction activities would be appropriate? a. Watching TV b. Playing games c. Books to read d. Mobiles or dangling ribbons

23. d. In the severe stage of AD, the patient is at a developmental level of 15 months or less; therefore appropriate distractions would be infant toys. Watching TV and playing games are more appropriate in the mild stage. Books to read would need to be at developmentally appropriate levels to be used as a diversion.

6. The husband of a patient is complaining that his wife's memory has been decreasing lately. When asked for examples of her memory loss, the husband says that she is forgetting the neighbors' names and forgot their granddaughter's birthday. What kind of loss does the nurse recognize this to be? a. Delirium b. Memory loss in AD c. Normal forgetfulness d. Memory loss in mild cognitive impairment

6. d. In mild cognitive impairment people frequently forget people's names and begin to forget important events. Delirium changes usually occur abruptly. In Alzheimer's disease the patient may not remember knowing a person and loses the sense of time and which day it is. Normal forgetfulness includes momentarily forgetting names and occasionally forgetting to run an errand.

7. The wife of a patient who is manifesting deterioration in memory asks the nurse whether her husband has AD. The nurse explains that a diagnosis of AD is usually made when what happens? a. A urine test indicates elevated levels of isoprostanes b. All other possible causes of dementia have been eliminated c. Blood analysis reveals increased amounts of β-amyloid protein d. A computed tomography (CT) scan of the brain indicates brain atrophy

7. b. The only definitive diagnosis of AD can be made on examination of brain tissue during an autopsy but a clinical diagnosis is made when all other possible causes of dementia have been eliminated. Patients with AD may have β-amyloid proteins in the blood, brain atrophy, or isoprostanes in the urine but these findings are not exclusive to those with AD.

Pre-test practice questions: A 78-year-old woman is in the intensive care unit after emergency abdominal surgery. The nurse notes that the patient is disoriented and confused, has incoherent speech, and is restless and agitated. Which action by the nurse is most appropriate? A) Reorient the patient. B) Notify the physician. C) Document the findings. D) Administer lorazepam (Ativan).

A) Reorient the patient. Rationale: The patient is exhibiting clinical manifestations of delirium. Care of the patient with delirium is focused on eliminating precipitating factors and protecting the patient from harm. Give priority to creating a calm and safe environment. The nurse should stay at the bedside and provide reassurance and reorienting information as to place, time, and procedures. The nurse should reduce environmental stimuli, including noise and light levels. Avoid the use of chemical and physical restraints if possible.

When administering a mental status examination to a patient with delirium, the nurse should a. wait until the patient is well-rested. b. administer an anxiolytic medication. c. choose a place without distracting stimuli. d. reorient the patient during the examination.

ANS: C-choose a place without distracting stimuli. Because overstimulation by environmental factors can distract the patient from the task of answering the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient's delirium.

The nurse is concerned about a postoperative patient's risk for injury during an episode of delirium. The most appropriate action by the nurse is to a. secure the patient in bed using a soft chest restraint. b. ask the health care provider to order an antipsychotic drug. c. instruct family members to remain with the patient and prevent injury. d. assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation.

ANS: D-assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation.

Pre-test practice questions: The nurse in the long-term care facility cares for a 70-year-old man with severe (late-stage) dementia who is undernourished and has problems chewing and swallowing. What should the nurse include in the plan of care for this patient? A) Turn on the television to provide a distraction during meals. B) Provide thickened fluids and moist foods in bite-size pieces. C) Limit fluid intake during scheduled meals to prevent aspiration. D) Allow the patient to select favorite foods from the menu choices.

B) Provide thickened fluids and moist foods in bite-size pieces. Rationale: If patients with dementia have problems chewing or swallowing, pureed foods, thickened liquids, and nutritional supplements should be provided. Foods that are easy to swallow are moist and should be in bite-size pieces. Distractions at mealtimes, including the television, should be avoided. Fluids should not be limited but offered frequently; fluids should be thickened. Patients with severe (late-stage) dementia have difficulty understanding words and would not have the cognitive ability to select menu choices.

NCLEX review questions: Which nursing intervention is most appropriate when caring for patients with dementia? Avoid direct eye contact. Lovingly call the patient "honey" or "sweetie." Give simple directions, focusing on one thing at a time. Treat the patient according to his or her age-related behavior.

C) Give simple directions, focusing on one thing at a time. Rationale: When dealing with patients with dementia, tasks should be simplified, giving directions using gestures or pictures and focusing on one thing at a time. It is best to treat these patients as adults, with respect and dignity, even when their behavior is childlike. The nurse should use gentle touch and direct eye contact. Calling the patient "honey" or "sweetie" can be condescending and does not demonstrate respect.

Bridge to NCLEX questions: Which statement(s) accurately describe(s) mild cognitive impairment (select all that apply)? a. Always progresses to AD b. Caused by variety of factors and may progress to AD c. Should be aggressively treated with acetylcholinesterase drugs d. Caused by vascular infarcts that, if treated, will delay progression to AD e. Patient is usually not aware that there is a problem with his or her memory

b. Caused by variety of factors and may progress to AD Rationale: Although some individuals with mild cognitive impairment (MCI) revert to normal cognitive function or do not go on to develop Alzheimer's disease (AD), those with MCI are at high risk for AD. No drugs have been approved for the treatment of MCI. A person with MCI is often aware of a significant change in memory.

The newly admitted patient has moderate AD. What does the nurse know this patient will need help with? a. Eating b. Walking c. Dressing d. Self-care activities

c. In the moderate stage of AD, the patient may need help with getting dressed. In the severe stage, patients will be unable to dress or feed themselves and are usually incontinent.

A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patient's speech is fragmented and incoherent. c. The patient is oriented to person but disoriented to place and time. d. The patient has a history of increasing confusion over several years.

ANS: A The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia.

NCLEX review questions: The patient is having some increased memory and language problems. What diagnostic tests will be done before this patient is diagnosed with Alzheimer's disease (select all that apply)? A) Urinalysis B) MRI of the head C) Liver function tests D) Neuropsychologic testing E) Blood urea nitrogen and serum creatinine

A) Urinalysis B) MRI of the head C) Liver function tests D) Neuropsychologic testing E) Blood urea nitrogen and serum creatinine Rationale: Because there is no definitive diagnostic test for Alzheimer's disease, and many conditions can cause manifestations of dementia, testing must be done to eliminate any other causes of cognitive impairment. These include urinalysis to eliminate a urinary tract infection, an MRI to eliminate brain tumors, liver function tests to eliminate encephalopathy, BUN and serum creatinine to rule out renal dysfunction, and neuropsychologic testing to assess cognitive function.

The nurse is administering a mental status examination to a 48-year-old patient who has hypertension. The nurse suspects depression when the patient responds to the nurse's questions with a. "Is that right?" b. "I don't know." c. "Wait, let me think about that." d. "Who are those people over there?"

ANS: B Answers such as "I don't know" are more typical of depression than dementia. The response "Who are those people over there?" is more typical of the distraction seen in a patient with delirium. The remaining two answers are more typical of a patient with mild to moderate dementia.

A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patient's speech is fragmented and incoherent. c. The patient is oriented to person but disoriented to place and time. d. The patient has a history of increasing confusion over several years.

ANS: A-The patient was oriented and alert when admitted The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia.

20. A 72-year-old woman is hospitalized in the intensive care unit (ICU) with pneumonia resulting from chronic obstructive pulmonary disease (COPD). She has a fever, productive cough, and adventitious breath sounds throughout her lungs. In the past 24 hours her fluid intake was 1000 mL and her urine output was 700 mL. She was diagnosed with early-stage AD 6 months ago but has been able to maintain her activities of daily living (ADLs) with supervision. Identify at least six risk factors for the development of delirium in this patient. (Fill in the blanks.) a. b. c. d. e. f.

20. a. Age; b. infection; c. hypoxemia (lung disease); d. intensive care unit (ICU) hospitalization (change in environment, sensory overload); e. preexisting dementia; f. dehydration. Also: hyperthermia and potentially medications to treat chronic obstructive pulmonary disease (COPD) and pneumonia.

What should be included in the management of a patient with delirium? a. The use of restraints to protect the patient from injury b. The use of short-acting benzodiazepines to sedate the patient c. Identification and treatment of underlying causes when possible d. Administration of high doses of an antipsychotic drug such as haloperidol (Haldol)

22. c. Care of the patient with delirium is focused on identifying and eliminating precipitating factors if possible. Treatment of underlying medical conditions, changing environmental conditions, and discontinuing medications that induce delirium are important. Drug therapy is reserved for those patients with severe agitation because the drugs themselves may worsen delirium.

8. To determine whether a new patient's confusion is caused by dementia or delirium, which action should the nurse take? a. Assess the patient using the Mini-Mental Status Exam. b. Obtain a list of the medications that the patient usually takes. c. Determine whether there is positive family history of dementia. d. Use the Confusion Assessment Method tool to assess the patient.

d. Use the Confusion Assessment Method tool to assess the patient. The Confusion Assessment Method tool has been extensively tested in assessing delirium. The other actions will be helpful in determining cognitive function or risk factors for dementia or delirium, but they will not be useful in differentiating between dementia and delirium.

13. The sister of a patient with AD asks the nurse whether prevention of the disease is possible. In responding, the nurse explains that there is no known way to prevent AD but there are ways to keep the brain healthy. What is included in the ways to keep the brain healthy (select all that apply)? a. Avoid trauma to the brain. b. Recognize and treat depression early. c. Avoid social gatherings to avoid infections. d. Do not overtax the brain by trying to learn new skills. e. Daily wine intake will increase circulation to the brain. f. Exercise regularly to decrease the risk for cognitive decline

13. a, b, f. Avoiding trauma to the brain, treating depression early, and exercising regularly can maintain cognitive function. Staying socially active, avoiding intake of harmful substances, and challenging the brain to keep its connections active and create new ones also help to keep the brain healthy.

9. A 62-year-old patient is brought to the clinic by a family member who is concerned about the patient's inability to solve common problems. To obtain information about the patient's current mental status, which question should the nurse ask the patient? a. "Where were you were born?" b. "Do you have any feelings of sadness?" c. "What did you have for breakfast?" d. "How positive is your self-image?"

c. "What did you have for breakfast?" This question tests the patient's recent memory, which is decreased early in Alzheimer's disease (AD) or dementia. Asking the patient about birthplace tests for remote memory, which is intact in the early stages. Questions about the patient's emotions and self-image are helpful in assessing emotional status, but they are not as helpful in assessing mental state.

A 56-year-old patient in the outpatient clinic is diagnosed with mild cognitive impairment (MCI).Which action will the nurse include in the plan of care? a. Suggest a move into an assisted living facility. b. Schedule the patient for more frequent appointments. c. Ask family members to supervise the patient's daily activities. d. Discuss the preventive use of acetylcholinesterase medications.

ANS: B Ongoing monitoring is recommended for patients with MCI. MCI does not interfere with activities of daily living, acetylcholinesterase drugs are not used for MCI, and an assisted living facility is not indicated for MCI.

Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had an appendectomy 2 days ago? a. Provide complete personal hygiene care for the patient. b. Remind the patient frequently about being in the hospital. c. Reposition the patient frequently to avoid skin breakdown. d. Place suction at the bedside to decrease the risk for aspiration.

ANS: B The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.

A patient who has severe Alzheimer's disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care? a. Encourage the patient to discuss events from the past. b. Maintain a consistent daily routine for the patient's care. c. Reorient the patient to the date and time every 2 to 3 hours. d. Provide the patient with current newspapers and magazines.

ANS: B Providing a consistent routine will decrease anxiety and confusion for the patient.

Which nursing actions could the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) who is part of the team caring for a patient with Alzheimer's disease (select all that apply)? a. Develop a plan to minimize difficult behavior. b. Administer the prescribed memantine (Namenda). c. Remove potential safety hazards from the patient's environment. d. Refer the patient and caregivers to appropriate community resources. e. Help the patient and caregivers choose memory enhancement methods. f. Evaluate the effectiveness of the prescribed enteral feedings on patient nutrition.

ANS: B, C LPN/LVN education and scope of practice includes medication administration and monitoring for environmental safety in stable patients. Planning of interventions such as ways to manage behavior or improve memory, referrals, and evaluation of the effectiveness of interventions require registered nurse (RN)-level education and scope of practice.

Bridge to NCLEX questions: Which patient is most at risk for developing delirium? a. A 50-year-old woman with cholecystitis b. A 19-year-old man with a fractured femur c. A 42-year-old woman having an elective hysterectomy d. A 78-year-old man admitted to the medical unit with complications related to heart failure

d. A 78-year-old man admitted to the medical unit with complications related to heart failure Rationale: Risk factors that can precipitate delirium include age of 65 years or older, male gender, and severe acute illness (e.g., heart failure). The 78-year-old man has the most risk factors for delirium

The nurse is administering a mental status examination to a 48-year-old patient who has hypertension. The nurse suspects depression when the patient responds to the nurse's questions with a. "Is that right?" b. "I don't know." c. "Wait, let me think about that." d. "Who are those people over there?"

ANS: B-"I don't know." Answers such as "I don't know" are more typical of depression than dementia. The response "Who are those people over there?" is more typical of the distraction seen in a patient with delirium. The remaining two answers are more typical of a patient with mild to moderate dementia.

Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia? a. Setting the medications up monthly in a medication box b. Having the patient's family member administer the medication c. Posting reminders to take the medications in the patient's house d. Calling the patient weekly with a reminder to take the medication

ANS: B-Having the patient's family member administer the medication Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the drug.

The spouse of a 67-year-old male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am exhausted from worrying all the time. I don't know what to do." Which actions are best for the nurse to take next (select all that apply)? a. Suggest that a long-term care facility be considered. b. Offer ideas for ways to distract or redirect the patient. c. Teach the spouse about adult day care as a possible respite. d. Suggest that the spouse consult with the physician for antianxiety drugs. e. Ask the spouse what she knows and has considered about dementia care options.

ANS: B, C, E The stress of being a caregiver can be managed with a multicomponent approach. This includes respite care, learning ways to manage challenging behaviors, and further assessment of what the spouse may already have considered for care options. The patient is in the early stages and does not need long-term placement. Antianxiety medications may be appropriate, but other measures should be tried first.

The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which action should the nurse take? a. Keep blinds open during the daytime hours. b. Provide hourly orientation to time and place. c. Have the patient take a brief mid-morning nap. d. Move the patient to a quieter room late in the afternoon.

ANS: A A likely cause of sundowning is a disruption in circadian rhythms and keeping the patient active and in daylight will help reestablish a more normal circadian pattern. Moving the patient to a different room might increase confusion. Taking a nap will interfere with nighttime sleep. Hourly orientation will not be helpful in a patient with dementia

1. The spouse of a male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am just exhausted from the constant worry. I don't know what to do." Which action is best for the nurse to take next (select all that apply)? a. Suggest that a long-term care facility be considered. b. Offer ideas for ways to distract or redirect the patient. c. Suggest that the spouse consult with the physician for antianxiety drugs. d. Educate the spouse about the availability of adult day care as a respite. e. Ask the spouse what she knows and has considered about dementia care options.

b. Offer ideas for ways to distract or redirect the patient. d. Educate the spouse about the availability of adult day care as a respite. e. Ask the spouse what she knows and has considered about dementia care options. The stress of being a caregiver can be managed with a multicomponent approach. This includes respite care, learning ways to manage challenging behaviors, and further assessment of what the spouse may already have considered. The patient is in the early stages and does not need long-term placement. Antianxiety medications may be appropriate but other measures should be tried first.

5. Which action will the nurse in the outpatient clinic include in the plan of care for a patient with mild cognitive impairment (MCI)? a. Suggest a move into an assisted living facility. b. Schedule the patient for more frequent appointments. c. Ask family members to supervise the patient's daily activities. d. Discuss the preventive use of acetylcholinesterase medications.

b. Schedule the patient for more frequent appointments. Ongoing monitoring is recommended for patients with MCI. MCI does not interfere with activities of daily living, acetylcholinesterase drugs are not used for MCI, and an assisted living facility is not indicated for MCI.

Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had an appendectomy 2 days ago? a. Provide complete personal hygiene care for the patient. b. Remind the patient frequently about being in the hospital. c. Reposition the patient frequently to avoid skin breakdown. d. Place suction at the bedside to decrease the risk for aspiration.

ANS: B-Remind the patient frequently about being in the hospital. The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.

14. During the morning change-of-shift report at the long-term care facility, the nurse learns that the patient with dementia has had sundowning. Which nursing action should the nurse take while caring for the patient? a. Provide hourly orientation to time of day. b. Move the patient to a quieter room at night. c. Keep blinds open during the daytime hours. d. Have the patient take a brief mid-morning nap.

c. Keep blinds open during the daytime hours. The most likely cause of sundowning is a disruption in circadian rhythms and keeping the patient active and in daylight will help to reestablish a more normal circadian pattern. Moving the patient to a different room might increase confusion. Taking a nap will interfere with nighttime sleep. Hourly orientation will not be helpful in a patient with memory difficulties.

Bridge to NCLEX questions: The clinical diagnosis of dementia is based on a. CT or MRS. b. brain biopsy. c. electroencephalogram. d. patient history and cognitive assessment.

d. patient history and cognitive assessment. Rationale: The diagnosis of dementia depends on determining the cause. A thorough physical examination is performed to rule out other potential medical conditions. Cognitive testing (e.g., Mini-Mental State Examination) is focused on evaluating memory, ability to calculate, language, visual-spatial skills, and degree of alertness. Diagnosis of dementia related to vascular causes is based on the presence of cognitive loss, the presence of vascular brain lesions demonstrated by neuroimaging techniques, and the exclusion of other causes of dementia. Structural neuroimaging with computed tomography (CT) or magnetic resonance imaging (MRI) is used in the evaluation of patients with dementia. A psychologic evaluation is also indicated to determine the presence of depression.

When administering a mental status examination to a patient with delirium, the nurse should a. wait until the patient is well-rested. b. administer an anxiolytic medication. c. choose a place without distracting stimuli. d. reorient the patient during the examination.

ANS: C Because overstimulation by environmental factors can distract the patient from the task of answering the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient's delirium.

When administering the Mini-Cog exam to a patient with possible Alzheimer's disease, which action will the nurse take? a. Check the patient's orientation to time and date. b. Obtain a list of the patient's prescribed medications. c. Ask the person to use a clock drawing to indicate a specific time. d. Determine the patient's ability to recognize a common object such as a pen.

ANS: C In the Mini-Cog, patients illustrate a specific time stated by the examiner by drawing the time on a clock face. The other actions may be included in assessment for Alzheimer's disease, but are not part of the Mini-Cog exam.

14. The son of a patient with early-onset AD asks if he will get AD. What should the nurse tell this man about the genetics of AD? a. The risk of early-onset AD for the children of parents with it is about 50%. b. Women get AD more often than men do, so his chances of getting AD are slim. c. The blood test for the ApoE gene to identify this type of AD can predict who will develop it. d. This type of AD is not as complex as regular AD, so he does not need to worry about getting AD.

14. a. The risk of early-onset AD for the children of parents with it is 50%. Women do get AD more often than men but that is more likely related to women living longer than men than to the type of AD. ApoE gene testing is used for research with late-onset AD but does not predict who will develop the disease. Late-onset AD is more genetically complex than early-onset AD and is more common in those over age 60 but because his parent has early-onset AD he is at a 50% risk of getting it.

15. A patient with moderate AD has a nursing diagnosis of impaired memory related to effects of dementia. What is an appropriate nursing intervention for this patient? a. Post clocks and calendars in the patient's environment. b. Establish and consistently follow a daily schedule with the patient. c. Monitor the patient's activities to maintain a safe patient environment. d. Stimulate thought processes by asking the patient questions about recent activities

15. b. Adhering to a regular, consistent daily schedule helps the patient to avoid confusion and anxiety and is important both during hospitalization and at home. Clocks and calendars may be useful in early AD but they have little meaning to a patient as the disease progresses. Questioning the patient about activities and events they cannot remember is threatening and may cause severe anxiety. Maintaining a safe environment for the patient is important but does not change the disturbed thought processes.

A 56-year-old patient in the outpatient clinic is diagnosed with mild cognitive impairment (MCI).Which action will the nurse include in the plan of care? a. Suggest a move into an assisted living facility. b. Schedule the patient for more frequent appointments. c. Ask family members to supervise the patient's daily activities. d. Discuss the preventive use of acetylcholinesterase medications.

ANS: B-Schedule the patient for more frequent appointments

NCLEX review questions: When providing community health care teaching regarding the early warning signs of Alzheimer's disease, which signs should the nurse advise family members to report (select all that apply)? A) Misplacing car keys B) Losing sense of time C) Difficulty performing familiar tasks D) Problems with performing basic calculations E) Becoming lost in a usually familiar environment

B) Losing sense of time C) Difficulty performing familiar tasks D) Problems with performing basic calculations E) Becoming lost in a usually familiar environment Rationale: Difficulty performing familiar tasks, problems with performing basic calculations, losing sense of time, and becoming lost in a usually familiar environment are all part of the early warning signs of Alzheimer's disease. Misplacing car keys is a normal frustrating event for many people.

Pre-test practice questions: Unlicensed assistive personnel (UAP) working for a home care agency report a change in the alertness and language of an 82-year-old female patient. The home care nurse plans a visit to evaluate the patient's cognitive function. Which assessment would be most appropriate? A) Glasgow Coma Scale (GCS) B) Confusion Assessment Method (CAM) C) Mini-Mental State Examination (MMSE) D) National Institutes of Health Stroke Scale (NIHSS)

C) Mini-Mental State Examination (MMSE) Rationale: The MMSE is a commonly used tool to assess cognitive function. Cognitive testing is focused on evaluating memory, ability to calculate, language, visual-spatial skills, and degree of alertness. The CAM is used to assess for delirium. The GCS is used to assess the degree of impaired consciousness. The NIHSS is a neurologic examination stroke scale used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss.