Chapter 24: Cognitive Disorders (Combined AJY)
Cognitive disorders are characterized by what?
Impaired attention, memory, and abstract thinking Explanation: Cognitive mental disorders are characterized by a disruption of or deficit in cognitive function, which encompasses orientation, attention, memory, vocabulary, calculation ability, and abstract thinking.
What is the primary sign of delirium?
An altered level of consciousness Explanation: The primary sign of delirium is an altered level of consciousness that is seldom stable and usually fluctuates throughout the day. All other options are not the primary sign of delirium.
In clients with Alzheimer's disease, neurotransmission is reduced, neurons are lost, and the hippocampal neurons degenerate. Which neurotransmitter is most involved in cognitive functioning?
Acetylcholine Explanation: Acetylcholine is involved in cognitive functioning. Epinephrine, serotonin, and norepinephrine are not as involved in cognitive functioning.
Which would not be considered a primary goal of nursing care for a client with delirium?
Achievement of self-esteem needs Explanation: Achievement of self-esteem needs would not be a primary goal of nursing care for the client diagnosed with delirium. All other options would be primary goals.
When giving tacrine to an elderly client, the nurse must be aware of what information?
Because the liver is most vulnerable to tacrine, liver function tests must be done periodically. Explanation: The liver rapidly absorbs and metabolizes tacrine; therefore, the liver is most vulnerable to the drug's toxicity.
A client has vascular neurocognitive disorder. When teaching the family about the cause of this disorder, which would the nurse expect to integrate into the explanation?
Blood flow in the vessels to the brain are blocked. Explanation: Vascular neurocognitive disorder, also called multi-infarct dementia, is caused by conditions that block or reduce blood flow to the brain. Tangles are found in clients with Alzheimer's disease, when proteins intended to provide stability in neurons are tangled together. Decreased acetylcholine production is thought to be a cause of Alzheimer's disease, with less of the enzyme needed to produce acetylcholine found in the brains of affected clients. Plaques are also found in the brains of clients with Alzheimer's disease. Proteins mix together to form plaques. The more plaques present, the more signs of degeneration are also found in affected clients.
A nurse is caring for a client diagnosed with delirium who has been brought for treatment by the client's adult child. While taking the client's history, which question would be most appropriate for the nurse to ask the client's adult child?
"Has your parent taken any medications recently?" Explanation: Delirium is typically caused by medications, urinary or upper respiratory tract infections, fluid and electrolyte imbalances, and metabolic disturbances. Therefore, questioning the adult child about the client's medication use would be most appropriate. Head injury or stroke may lead to changes in consciousness but not delirium. Although acute or chronic stress may be a risk factor for the development of delirium, this would not be the most appropriate question to ask at this time.
The nurse assesses a client who has received a tentative diagnosis of delirium and explains to the family about the major cause of the client's condition. Which statement by the nurse would be most appropriate?
"The client's diagnosis is primarily based on the rapid onset of the change in consciousness." Explanation: The key diagnostic indicator for delirium is impaired consciousness, which is usually sudden in onset. Although infection may be an underlying cause, and other cognitive changes may occur such as problems with memory, orientation, and language, impaired consciousness developing over a short period is key.
A 35-year-old client is delirious after being lost in the woods for several days and becoming severely dehydrated. At 9 p.m. the client tells the nurse to get the client's clothes because the client has to get home to the client's family. Which response by the nurse is most therapeutic?
"You're in the hospital. You did not drink for several days, but you're getting better now." Explanation: Staff members can try to direct the client's activity and cognitive focus by reorienting the client to the environment with displays of calendars, clocks, and decorations commemorating upcoming holidays. Therapeutic communications concerning the day's activities, repetition of facts concerning why the client is hospitalized, and reassurance that the hallucinations and delusions experienced are part of the transient condition of delirium are helpful.
An older client has recently finished treatment for a urinary tract infection (UTI) and has now developed changes in behavior resulting in decreased cognition. Which priority intervention(s) should the nurse perform? Select all that apply. -Stop the prescribed antibiotic therapy. -Contact the health care provider. -Maintain adequate hydration. -Obtain an order for sedation. -Obtain a repeat urine culture.
-Contact the health care provider. --Maintain adequate hydration. -Obtain a repeat urine culture. Explanation: Because the older client has finished treatment for the UTI, there is no need for the nurse to stop the prescribed antibiotic therapy. It would be important for the nurse to contact the health care provider and appraise them of the client's present cognitive status. Maintaining adequate hydration is also a priority, as is obtaining a repeat urine culture to make sure that the UTI has resolved and to rule out dehydration. There is no need to sedate the client as they are already experiencing decreased cognition.
After teaching a group of nursing students about delirium, the instructor determines a need for additional teaching when the students identify which as a primary goal of nursing care?
Achievement of self-esteem needs Explanation: The primary goal of treatment of individuals with delirium is prevention or resolution of the acute confusional episode with return to previous cognitive status and interventions focusing on (1) elimination or correction of the underlying cause and (2) symptomatic and safety and supportive measures. Self-esteem is not an issue with delirium.
When assessing a client with dementia, the nurse notes that the client is having difficulty identifying common items, such as a ball or book. The nurse interprets this finding as what?
Agnosia Explanation: The client's difficulty in identifying objects is considered agnosia. With dementia, typical deficits include aphasia (alterations in language ability), apraxia (impaired ability to execute motor activities despite intact motor functioning), agnosia (failure to recognize or identify objects despite intact sensory function), or a disturbance of executive functioning (ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior).
The nurse is caring for a client with dementia. The client's brain images show atrophy of cerebral neurons and enlargement of the third and fourth ventricles. What is the cause of dementia in this client?
Alzheimer's disease Explanation: The client's brain images show atrophy of cerebral neurons and enlargement of the third and fourth ventricles. These findings are indicative of Alzheimer's disease. In Picks's disease, there is degeneration of frontal and temporal lobes. In vascular dementia there are multiple vascular lesions of the cerebral cortex and subcortical structures. In Parkinson's disease, the primary pathology is the loss of neurons in the basal ganglia
The nurse is performing an admission assessment for a client who is suspected of having dementia. Which finding would the nurse most likely document as a subjective finding?
Answers by the client and family to questions about emotional changes Explanation: Answers to question posed to the client or family about emotional changes would be documented as subjective findings. Testing the client's ability to remember unrelated words and recent events, assessing the client's level of consciousness, and determining cortical function by the client's ability to perform arithmetic are all objective assessments.
A client diagnosed with Alzheimer's disease has an alteration in language ability. This alteration would be documented as what?
Aphasia Explanation: Aphasia is an alteration in language ability. Agnosia is the failure to recognize or identify objects despite intact sensory function. Apraxia is impairment in the ability to execute motor activities despite intact motor functioning. Akinesia is impaired muscle movement that may occur in Parkinson's disease.
A client was admitted to an inpatient unit with a diagnosis of dementia. A nursing assessment and interview of the client would include what?
Intellectual ability, health history, and self-care ability Explanation: A comprehensive nursing assessment should include obtaining the premorbid intellectual ability, health history, and self-care abilities of the client. The medical assessments, which are important, are not as critical to nursing assessment as the actions in the correct answer. Exploring early parent-child conflict and relational patterns would not be helpful with the dementive process.
Changes that are found during the mental status examination of a client diagnosed with delirium include what?
Difficulty focusing Explanation: The mental status evaluation reveals several changes, including fluctuations in level of consciousness with reduced awareness of the environment; difficulty focusing and sustaining attention, or difficulty shifting attention; and severely impaired memory, especially immediate and recent memory.
The spouse caregiver of a client with dementia tells the nurse that the client has been agitated lately. The spouse states, "I don't know how to handle this. The client was always such a gentle person!" Which interventions should the nurse suggest?
Distract the client with family photos and discuss the events pictured. Explanation: At times, there may seem to be no way to resolve the emotional frustration, agitation, or outbursts of the client who is angry with the environment and those in it. The caregiver might find it beneficial to redirect or distract the client. This can be done by asking to see a client's personal items, such as photographs, and then talking about the family members and life events illustrated by the photographs in the book.
A client with Alzheimer's disease is admitted to an acute care facility for treatment of an infection. Assessment reveals that the client is anxious. When developing the client's plan of care, which would be least appropriate for a nurse to include?
Frequently provide reality orientation Explanation: The threshold for stress is progressively lowered in people with Alzheimer's disease and other progressive dementias. A healthy person frequently uses cognitive coping strategies when under stress, but a person with dementia can no longer use many of these strategies. Commonly used therapeutic approaches may exacerbate anxiety in a client with dementia. For example, reality orientation is usually an effective intervention for acutely confused clients. Reality orientation is contraindicated in those with dementia because it is possible that the client's disoriented behavior or language has inherent meaning. If the disoriented behavior or language is continuously neglected or corrected, the client's sense of isolation and anxiety may increase. Effective nursing interventions include simplifying routines, making routines as consistent and predictable as possible, reducing the number of choices the client must make, identifying areas in which control can be maintained, and creating an environment in which the client feels safe.
A nurse is providing education to the care provider of a cognitively impaired client who is prescribed a cholinesterase inhibitor. Which information about medication side effects should the nurse be sure to include?
Gastrointestinal (GI) symptoms Explanation: All four of the commonly prescribed cholinesterase inhibitors have the possibility of producing GI symptoms.
Delirium can be differentiated from many other cognitive disorders in which way?
It has a rapid onset and is highly treatable if diagnosed quickly. Explanation: Delirium often is caused by an acute disruption of brain homeostasis. When the cause of that disruption is eliminated or subsides, the cognitive deficits usually resolve within a few days or sometimes weeks. Dementia, in contrast, results from primary brain pathology that usually is irreversible, chronic, progressive, and less amenable to treatment.
The client is an 84-year-old suffering from delirium. The client has been in a nursing home for the past 2 years but recently is becoming combative and has become a threat to staff. Which medication would the client most likely receive for these symptoms?
Haloperidol Explanation: Staff members must seriously consider this option when a client's behavior threatens the safety of self, family, or staff. Haloperidol, a neuroleptic given either orally or by injection, is most commonly used for symptoms of delirium.
A client with amnestic disorder is being evaluated for dementia. Which is a diagnostic characteristic of amnestic disorder?
History and physical examination indicative of memory impairment Explanation: Diagnostic characteristics of amnestic disorder include memory impairment not solely limited to periods of delirium, history and physical examination indicative of medical condition underlying the memory impairment, demonstration of significant problems with social or occupational functioning, and memory significantly decreased from usual level.
A nurse is preparing a presentation for a group of staff nurses about neurocognitive disorders. When describing vascular neuorocognitive disorder, the nurse would identify which as posing the greatest risk for this disorder?
Hypertension Explanation: Vascuar neurocognitive disorder involves a series of small strokes that damage or destroy brain tissue. The primary causes of these strokes include high blood cholesterol levels, diabetes, heart disease, and high blood pressure. Of these, high blood pressure is the greatest risk factor for vascular neurocognitive disorder.
Which is the primary treatment for delirium?
Identify and treat any causal or contributing medical conditions Explanation: The primary treatment of delirium is to identify and treat any causal or contributing medical conditions.
Which medication is not known to cause delirium?
Loop diuretics Explanation: Loop diuretics are not known to causes delirium. Steroids, narcotics, and antidepressants may cause delirium.
A client is exhibiting signs of mild delirium such as occasional confusion about why the client is in the hospital and what day of the week it is. When developing a care plan, the nurse identifies several strategies to improve the client's cognitive function. Which intervention will be helpful to the client?
Make up a daily calendar with the date and the times of scheduled activities. Explanation: The confused client will be calmer when the nurse eliminates environmental stimuli that invite misinterpretation, such as abstract pictures on the wall or excessive background noise and television. Conversely, the nurse can provide environmental cues in the form of clocks, recognizable pictures, and calendars to help restore orientation to time and place. A caveat to reducing environmental stimuli is to not create an understimulating environment, which can be just as detrimental as an overstimulating one. The key is to remove abstract or difficult-to-interpret environmental cues and replace them with simple, easy-to-recognize ones.
Which of these is a N-methyl-D-aspartic acid (NMDA) receptor antagonist?
Memantine Explanation: Memantine is a NMDA receptor antagonist that has been shown to improve cognition and activities of daily living in clients with moderate to severe symptoms of dementia. Galantamine, donepezil, and rivastigmine are cholinesterase inhibitors.
A client with a medical diagnosis of dementia of Alzheimer's type has been increasingly agitated in recent days. As a result, the nurse has identified the nursing diagnosis of "risk for injury related to agitation and confusion" and an outcome of "the client will remain free from injury." What intervention should the nurse use in order to facilitate this outcome?
Monitor amount of environmental stimulation and adjust as needed. Explanation: Overstimulation from the environment is a likely trigger for agitation. The nurse must monitor the environment and the client's response to it on an ongoing basis. Seclusion would be unsafe. Teaching and setting limits are unlikely to be effective interventions with a client who has a cognitive disorder due to limitations of cognitive processing and impaired short-term memory.
While reviewing the medical record of a client diagnosed with moderate dementia of the Alzheimer type, a nurse notes that the client has been receiving memantine. The nurse identifies this drug as which type?
N-methyl-D-aspartate (NMDA) receptor antagonist Explanation: Memantine is classified as an NMDA receptor antagonist that has been shown to improve cognition and activities of daily living in clients with moderate to severe symptoms of dementia. Risperidone, olanzapine, and quetiapine are examples of atypical antipsychotics. Galantamine, donepezil, rivastigmine, and tacrine are cholinesterase inhibitors. Clonazepam, alprazolam, and lorazepam are examples of benzodiazepines.
A group of nursing students is reviewing information about delirium and its causes. The students demonstrate a need for additional review when they identify which as a cause of this medical condition?
Oxidative stress Explanation: Oxidative stress is associated with dementia. The etiology of delirium is complex and multifaceted. Delirium is associated with medications, infections, fluid and electrolyte imbalance, metabolic disturbances, or hypoxia or ischemia. The probability of the syndrome developing increases if certain predisposing factors, such as advanced age, brain damage, or dementia, are also present. Sensory overload or underload, immobilization, sleep deprivation, and psychosocial stress also contribute to delirium.
A client has experienced a gradual flattening of affect, confusion, and withdrawal and has been diagnosed with Alzheimer's disease. Which additional findings would the nurse most likely assess?
Personality change, wandering, and inability to perform purposeful movements Explanation: Alzheimer's disease is not typically characterized by delusions, transient paresthesias, blindness, or slurred speech. Instead, general changes in personality, wandering, and the inability to perform purposeful, goal-directed movements are impaired.
A client with dementia becomes extremely agitated shortly after being admitted to the psychiatric unit. The nurse is reluctant to use physical restraints to control the client. What is a likely reason the nurse has this reluctance?
Physical restraints may increase the client's agitation. Explanation: The use of physical restraints are usually a last resort for clients with dementia, as restraint use may increase any fears or thoughts of being threatened. The nurse may need to use physical restraints if the client is pulling at intravenous lines or catheters. Physical restraints do not commonly cause injury to the client or lead to fatality.
An older adult client develops delirium secondary to an infection. Which would be the most likely cause?
Pneumonia Explanation: Delirium in the older adult is associated with medications, infections, fluid and electrolyte imbalance, metabolic disturbances, or hypoxia or ischemia. Infections of the respiratory tract such as pneumonia or urinary tract are among the most common infection-related causes. Appendicitis and cellulitis are not commonly associated with the development of delirium. Although low platelet count would render the older adult vulnerable to bleeding and easy bruising, it does not increase the risk of delirium.
The client has advanced Alzheimer's disease and becomes confused at mealtimes. The client has agnosia, apraxia, and disturbed executive functioning. Which is the most appropriate nursing intervention?
Provide the client with a tray, opening containers for the client. Explanation: The ability of clients to care for themselves decreases as the severity of the cognitive order increases. Caregivers can help by enhancing the client's environment to facilitate his or her limited ability to perform activities of daily living and instrumental activities of daily living and by fulfilling unmet client needs.
A client is in the mild stage of dementia due to Alzheimer's disease. Which intervention would be most appropriate?
Providing emotional support and gentle reminders Explanation: Clients in the mild stage of Alzheimer's disease are aware that something is happening to them and may become forgetful, have difficulty finding words, frequently lose objects and begin to experience some anxiety regarding the forgetfulnes. Therefore, nursing care typically focuses on providing emotional support and gentle reminders. The other options are appropriate as the dementia progresses and the client needs continuous monitoring to prevent injuries and when maintaining adequate nutrition may become a challenge. During the later stages, the client will likely need to be moved to a care home to ensure the client is safe and can meet the activities of daily living. At this point, adequate nutrition can only be ensured by having the client monitored throughout the day, providing additional support for the decision to move the client to a care home.
A care aide has rung the call light for assistance while providing a client's twice-weekly bath because the client became agitated and aggressive while being undressed. Knowing that the client has a diagnosis of dementia of Alzheimer's type and is prone to agitation, which measure may help in preventing this client's agitation?
Reminding the client multiple times that he or she will be soon having a bath Explanation: Adequately preparing a client for a task can sometimes prevent episodes of agitation or aggression. Reminding a cognitively impaired client about policies is unlikely to be effective, and decreasing the frequency of baths will not necessarily prevent agitation. It is not normally appropriate to change a client's medication administration schedule in light of activities such as bathing.
A nurse's aide has rung the call light for assistance while providing a client's twice-weekly bath because the client became agitated and aggressive while being undressed. Knowing that the client has a diagnosis of Alzheimer's disease and is prone to agitation, which measure may help in preventing this client's agitation?
Reminding the client multiple times that he or she will be soon having a bath Explanation: Adequately preparing a client for a task can sometimes prevent episodes of agitation or aggression. Reminding a cognitively impaired client about policies is unlikely to be effective, and decreasing the frequency of baths will not necessarily prevent agitation. It is not normally appropriate to change a client's medication administration schedule in light of activities such as bathing.
The nurse is assessing a client who is diagnosed with delirium. Which presenting sign in the client indicates to the nurse that the client may have a diagnosis of dementia?
Remote memory loss Explanation: Impaired memory may be present in both delirium and dementia. However, remote memory loss, which can manifest as forgetting the names of adult children, the client's former occupation, or even the client's own name, occurs in the later stages of dementia. Irrelevant speech, visual hallucinations, and impaired consciousness are signs of delirium. In dementia, speech is normal during the initial stages and then progresses to aphasia. Hallucinations may be present in dementia but are typical of delirium. Consciousness is usually not impaired in client with dementia.
An older client transferred from a nursing home presents to the emergency department in an agitated state. The nurse is unable to obtain a coherent response to any questions posed. What is the best nursing action?
Review medication profile record. Explanation: At the present time, additional information is needed to determine whether the older client is experiencing delirium or dementia; therefore, the priority would be to review the medication profile record to see if any prescribed medications are causing delirium. Although the client is agitated, there is insufficient evidence for the use of restraints and using them could cause the confusion to worsen. Making sure that all side rails are up is a form of a restraint. Sedating the client with medication may eventually be needed. but it is not the priority action. The nurse must identify the cause of confusion and agitation prior to using medications.
Which nursing diagnosis would be the priority for the client experiencing acute delirium?
Risk for injury related to confusion and cognitive deficits Explanation: The plan of care must be deliberately designed to meet the client's unique needs, with safety always being the nurse's highest priority. Risk for injury is a NANDA diagnosis and the etiology of confusion and cognitive deficits are factors that can be modified through nursing care.
A client is diagnosed with dementia that has progressed significantly. Which would be the priority for this client?
Safety Explanation: The priority of care changes throughout the course of dementia. Initially, the priority is delaying cognitive decline and supporting family members. Later the priority is protecting the client from injury because of lack of judgment.
Which can be identified as a hallmark symptom of dementia?
Short-term memory loss Explanation: As a broad diagnosis, dementia includes conditions in which short-term memory loss is a hallmark. The deterioration of memory is so great that it prevents clients from functioning at previous levels of social and occupational performance and seriously deters them from learning new information.
The nurse receives a report that a 75-year-old client is recovering from surgery. During the shift, the nurse notes that the client is forgetful and restless. Several times, the client calls the nurse the name of the client's daughter. The nurse interprets this behavior as what?
Signs of delirium Explanation: Delirium is a syndrome characterized by a rapid onset of cognitive dysfunction and disruption in consciousness. Growing rates of delirium mirror the increasing older adult population and are expected to continue to rise. Delirium is the most common psychiatric syndrome in general hospitals, occurring in up to 50% of elderly inpatients. It is associated with significantly increased morbidity and mortality both during and after hospitalization.
The client is 42 years old, married, and has two children, ages 16 and 18. The client is also caring for the client's parent, who is in the late stages of Alzheimer's disease. The nurse would want to assess the client for what?
Signs of stress Explanation: Nurses must assess family members, especially caregivers, for signs of stress or burnout. Although this issue might not be pertinent during early stages of dementia, it becomes paramount as clients progressively degenerate and demands for physical care mount.
Which medication used to treat dementia requires a liver function test every 1 to 2 weeks?
Tacrine Explanation: Tacrine requires a liver function tests every 1 to 2 weeks.
The psychiatric nurse documents that the cognitively impaired client is exhibiting "confabulation" when observed doing what?
Telling other clients that the client "was a dairy farmer" when the client actually ran a small grocery store Explanation: Confabulation is the filling in of memory gaps with false but sometimes plausible content to conceal the memory deficit, such as a client telling others that the client "was a dairy farmer" when the client actually ran a small grocery store. Evidence of perseveration is a client telling the staff repeatedly that "my name is George and I'm hungry." Sundown syndrome can be described as a client pacing nervously and resisting the staff's request to "get ready for bed." Concrete thinking is described when the client asks where the cats are when told it's "raining cats and dogs."
An older client comes to the clinic for a yearly physical exam. During the assessment, the client tells the nurse that the client sometimes has begun feeling anxious about the client's forgetfulness. The nurse notes the client may have mild dementia. Which finding would lead the nurse to conclude this?
The client has difficulty finding words Explanation: The nurse suspects the client may have mild dementia as the client is reporting difficulty in finding words during conversation, along with anxiety over the client's forgetfulnesss. Confusion and the inability to perform complex tasks are possible indicators of moderate dementia. Delusions are typically experienced by client's suffering from severe dementia.
The client has early Alzheimer's disease. When asked about family history, the client relates that the client has two children who are both grown and who visit the client around the holidays each year. The nurse subsequently discovers that the client has one child who is currently assigned overseas and who has not been home for 2 years. Which would best describe the client's behavior?
The client is confabulating, most likely to cover for memory deficit. Explanation: The client may have some difficulty recalling events or knowledge that the client formerly knew to be fact. Because of the inability to recall recent events, the client may be confabulating, or filling in memory gaps with fabricated or imagined data.
The nurse is assessing a client with aphasia and notes the client may be exhibiting echolalia during their conversation. What signs does the nurse observe that leads to this conclusion?
The client may echo whatever is heard. Explanation: A client suffering from aphasia may exhibit echolalia, or echoing what is heard during conversation. Clients who repeat words and sounds over and over are suffering from palilalia. Difficulty forming sentences and producing vague speech that is difficult to interpret can be seen in clients with dementia.
The nurse is interviewing a 50-year-old with a suspected cognitive disorder. The client has a long history of alcoholism. When the nurse asks if the client is employed, the client replies that the client is currently employed as a conductor on a national railway system. The client's spouse takes the nurse aside and informs the nurse that the client hasn't worked for several years and never worked for the railway. The nurse attributes the client's answer to which explanation?
The client may have Korsakoff's syndrome. Explanation: Korsakoff's syndrome usually is found in the 40- to 70-year-old client with alcoholism and a history of steady and progressive alcohol intake. In time, this person develops a vitamin B1 (thiamin) deficiency that directly interferes with the production of the brain's main nutrient, glucose, resulting in the symptomatology of this syndrome. A client with this disorder has great difficulty with recent memory, specifically the ability to learn new information. Because of the inability to recall recent events, the individual fills in memory gaps with fabricated or imagined data (confabulation).
The nurse asks a client to pretend the client is brushing the client's teeth. The client is unable to perform the action. Upon examination, the nurse finds that the client possesses intact motor abilities. What can this problem be documented as?
The client may have apraxia. Explanation: Impaired ability to execute motor functions despite having intact motor abilities is referred to as apraxia. In this case, the client knows how to and has the physical abiltiy to brush the client's teeth but is unable to demonstrate the action upon request. Thus the client has apraxia. The inability to recognize or name objects or sounds heard is referred to as agnosia. Aphasia is the deterioration of language function. Disturbed executive function is the inability to carry out complex motor activities. Using a toothbrush is not a complex activity.
A 65-year-old has been admitted to the intensive care unit following surgical resection of the bowel. The client has developed a fever. Which additional signs indicate the client has developed delirium?
The client removes the client's surgical bandage and begins picking at the sheets. Explanation: Features of delirium may include a reduced level of consciousness, a disrupted sleep-wake cycle, and an abnormality of psychomotor behavior. The hospitalized client with delirium will try to remove intravenous lines and other tubes, "pick" at the air or the bed sheet, and try to climb over side rails or the end of the bed.
The diagnosis of delirium is supported when the nurse notes what about the client?
The client reports seeing "hundreds of bugs" and is not always oriented to time and place Explanation: The diagnosis of delirium is supported when the nurse documents that the client is convinced that the client sees hundreds of bugs and is not always oriented to time and place. Repeatedly asking about location and attempting to drink the water in a flower vase are more characteristic of dementia than delirium. Spending much of the day sleeping in the dayroom and usually denying being hungry are more representative of depression, as are responding to most assessment questions with "I don't know" and appearing apathetic.
Major goals for the nursing care of clients with dementia should include what?
The client will be safe, be physiologically stable, and have infrequent episodes of agitation. Explanation: Safety is always the nurse's first priority; clients with dementia often cannot meet their basic physical needs and agitation is a common emotional response to confusion and disorientation.
An 82-year-old client with a diagnosis of vascular dementia has been admitted to the geriatric psychiatry unit of the hospital. In planning the care of this client, which outcome should the nurse prioritize?
The client will remain free from injury. Explanation: Control of agitation and promotion of self-worth are important outcomes, but safety is a priority concern. A client whose diagnosis necessitates hospitalization may or may not be capable of identifying or making changes in life routines.
The nurse preparing an educational program on dementia should include which information?
The onset of symptoms of dementia is gradual Explanation: Dementia refers to a syndrome of global or diffuse brain dysfunction characterized by a gradual, progressive, chronic deterioration of intellectual function.
A nurse is caring for a client with delirium. The nurse assesses the client's activities of daily living on a daily basis. What is the most likely reason for assessing these so frequently?
To assess for fluctuation in the client's capabilities Explanation: Clients with organic diseases like delirium tend to have fluctuations in their ability to carry out activities of daily living. Thus, the nurse should assess these daily. Although the nurse should encourage the client to make decisions about treatment and assist the client in establishing a daily routine, these actions do not require daily assessment. Assess the prognosis of the client after therapy also is not required daily.
The nurse is working with the family of a client who is newly diagnosed with Alzheimer's type dementia. Which suggestion would be effective for assisting the family members in daily orienting of their family member when the client returns home?
Use daily newspapers, calendars, and a set routine. Explanation: Using daily newspapers, calendars, and a set, unchanging routine would be a more effective way to provide daily orientation for the family member. Changing daily activities would make it more difficult to maintain orientation. Reading to the client for long periods of time would not maintain client involvement and appropriate stimulation. Using daily quizzes would place stressful demands on the client and not provide functionally appropriate tasks.
To manage voiding issues, such as incontinence, male clients diagnosed with dementia would best be managed by what?
Use of disposable, adult diapers Explanation: Urinary incontinence can be managed with the use of disposable, adult-size diapers that must be checked regularly and changed expeditiously when soiled. Indwelling catheters foster the development of urinary tract infections and may compromise the client's dignity and comfort. Use of intermittent catheterization and condom catheters would not be the best options, either
Which type of hallucination is most commonly seen in clients diagnosed with delirium?
Visual Explanation: Visual hallucinations are the most common type seen in clients diagnosed with delirium.
Which type of hallucination most commonly occurs in clients diagnosed with dementia?
Visual Explanation: Visual, rather than auditory, hallucinations are the most common in those with dementia. Auditory, gustatory, and olfactory hallucinations are not the most common type seen in people with dementia.
An older adult with no significant medical history is admitted to the hospital through the emergency department after hitting the client's head during a fall and fracturing the humerus. The client does not require surgery and will probably be discharged the following day. Should the nurse be concerned about delirium?
Yes, because of the head injury and medication Explanation: This client is an older adult who has suffered trauma and, given the injuries, is likely receiving medication for pain. Certain clients are at increased risk for delirium, specifically older adults and cognitively impaired older adults recovering from surgery. Older adults are especially susceptible to delirium disorders because the aging neurologic system is particularly vulnerable to insults caused by underlying systemic conditions. Indeed, delirium often predicts or accompanies physical illness in older adults. An underlying disease process is not necessary for this injured older adult to be at risk for delirium, and length of hospitalization is irrelevant. While an unfamiliar environment and overstimulation can exacerbate delirium, these are not risk factors for developing it.
Directed by evidence-based practice, the psychiatric nurse minimizes the milieu's dementia-induced aggressive behavior by:
adhering to a predictable dressing routine. Explanation: Research has shown that attempting to change the dressing behavior of clients with dementia may result in physical aggression as clients make ineffective attempts to resist unwanted change.
Family members bring an older client, recently diagnosed with Alzheimer disease, to the clinic stating they need placement in a facility for their loved one. Which finding would support further assistance in care giving for this client?
client wandering off Explanation: Alzheimer disease (AD) is a progressive neurological, neuropsychiatric disorder that results in cognitive, functional, physical, and behavioral decline and ultimately death. Typically, AD presents late onset in age, but it can also occur early onset in age. There are three stages of progression: mild, moderate, and severe. Wandering is associated with the moderate stage. Wandering off and incontinence are the main factors leading to placement of individuals in care facilities. Maintaining a stoic affect is seen in the mild stage. Preference of taking showers is not considered a reason for placement.
What is the initial intervention the nurse should implement when helping a client diagnosed with dementia deal with paranoid delusions?
observe the client in order to identify the triggers for the delusions Explanation: Clients with dementia may believe that their physical safety is jeopardized; they may feel threatened or suspicious and paranoid. These feelings can lead to agitated or erratic behavior that compromises safety. Avoiding direct confrontation of the client's fears is important. Clients with dementia may struggle with fears and suspicion throughout their illness. Triggers of suspicion include strangers, changes in the daily routine, or impaired memory. The nurse must discover and address these environmental triggers rather than confront the paranoid ideas.
What is the greatest benefit support groups provide to the caregivers of clients diagnosed with dementia?
provides interaction with those with similar concerns Explanation: Attending a support group regularly also means that caregivers have time with people who understand the many demands of caring for a family member with dementia. While the other options suggest accurate results, none are the greatest benefit such a support group experience can provide.
