Lewis 59: Dementia and Delirium

Benzodiazepines are indicated in the treatment of delirium caused by which condition? A. Polypharmacy B. Cerebral hypoxia C. Alcohol withdrawal D. Electrolyte imbalances

C. 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.

The patient is having some increased memory and language problems. What diagnostic tests will be done before this patient is diagnosed with AD? Select all that apply. A. Urinalysis B. Chest x-ray C. MRI of the head D. Liver function tests E. Neuropsychologic testing F. Blood urea nitrogen (BUN) and serum creatinine

A, C, D, E, & F. Because there is no definitive diagnostic test for AD, 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 (UTI), an MRI to eliminate brain tumors, liver function tests to eliminate encephalopathy, BUN and creatinine to rule out renal dysfunction, and neuropsychologic testing to assess cognitive function. A chest x-ray examination is not used to investigate an alternate cause of memory or language problems.

When caring for a patient with Alzheimer's disease (AD), which task could be delegated to the LPN/VN on the team? A. Administer enteral feedings via gastrostomy tube B. Teach patient and caregivers memory enhancement aids C. Use bed alarms and frequent monitoring to decrease fall risk D. Make referrals for community services such as adult day care

A. Administering enteral feedings via gastrostomy tube is within the scope of practice for the LPN/VN. The RN will be responsible for individualized patient teaching and referrals. The UAP will be able to use bed alarms and frequently monitor the patient.

The nurse determines that a history of which mental health disorder would support the prescription of taking donepezil? A. Dementia B. Schizophrenia C. Seizure disorder D. Obsessive-compulsive disorder (OCD)

A. Donepezil hydrochloride is a cholinergic agent that is used in the treatment of mild to moderate dementia of the Alzheimer's type. It increases concentration of acetylcholine, which slows the progression of Alzheimer's disease. The other options are incorrect and are not indications for use of this medication.

Which patient should receive a depression assessment first? A. A patient in the early stages of AD B. A patient who is in the final stage of AD C. A patient experiencing delirium secondary to dehydration D. A patient who has become delirious following an atypical drug response

A. Patients in the early stages of AD are particularly susceptible to depression because they are acutely aware of their cognitive changes and the expected disease trajectory. Delirium is typically a short-term health problem that does not typically pose a heightened risk of depression.

The nurse is developing a plan of care for a patient with late-stage Alzheimer's disease. The nurse identifies which patient problem as having the highest priority? A. Risk for injury B. Social isolation behaviors C. Role performance alterations D. Inability to communicate verbally

A. Patients who have Alzheimer's disease have significant cognitive impairment and are therefore at risk for injury. It is critical for the nurse to maintain a safe environment, particularly as the patient's judgment becomes increasingly impaired. B, C, and D may be appropriate, but the highest priority is directed toward safety.

The nurse has administered a dose of risperidone (Risperdal) to a patient with delirium. What finding demonstrates the intended effect of the medication? A. Lying quietly in bed B. Alleviation of depression C. Reduction in blood pressure D. Disappearance of confusion

A. 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.

The nurse is performing an assessment on a patient with dementia. Which piece of data gathered during the assessment indicates manifestations associated with dementia? A. Use of confabulation B. Improvement in sleeping C. Absence of sundown syndrome D. Presence of personal hygienic care

A. The clinical picture of dementia ranges from mild cognitive deficits to severe, life-threatening alterations in neurological functioning. For the client to use confabulation or the fabrication of events or experiences to fill in memory gaps is not unusual. Often, lack of inhibitions on the part of the client may constitute the first indication of something being "wrong" to the client's significant others (e.g., the client may undress in front of others, or the formerly well-mannered client may exhibit slovenly table manners). As the dementia progresses, the client will have difficulty sleeping and episodes of wandering or sundowning.

A 68-yr-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.

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.

A priority goal of treatment for the patient with Alzheimer's disease (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. 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.

A 78-yr-old woman was transferred to the intensive care unit (ICU) after emergency abdominal surgery. The nurse notes the patient is disoriented and confused, has incoherent speech, is restless, and agitated. Which action by the nurse is most appropriate? A. Reorient the patient B. Document the findings C. Notify the HCP D. Administer lorazepam (Ativan)

A. The patient has 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.

Which statement by the wife of a patient with 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. "The medications might prevent a bodily decline while he declines mentally" D. "If we follow his medication schedule, he may not have any physical effects of his disease"

A. There is presently no cure for AD, and drug therapy aims at improving or controlling decline in cognition. Medications do not directly address the physical manifestations of AD.

A 59-yr-old female patient with a frontotemporal lobar dementia has difficulty with verbal expression. While her husband was at work, she walked to the gas station for a soda but did not understand the request for payment. What can the nurse suggest to keep the patient safe? A. Adult day care B. Assisted living C. Advanced directives D. Monitor for behavioral changes

A. To keep the 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. Advanced directives are important but are not related to her safety. Monitoring for behavioral changes will not keep her safe during the day.

Which newly hospitalized patient should the nurse monitor closely for development of delirium? A. A 48-yr-old who usually drinks a six-pack a day B. A 68-yr-old who takes aspirin 650 mg twice daily for arthritic pain C. A 72-yr-old who says, "I have a glass of wine every evening to stimulate my appetite" D. A 78-yr-old diabetic whose blood glucose levels are consistently greater than 250 mg/dL

A. Withdrawal from alcohol, anxiolytics, opioids, and central nervous system stimulants presents a significant risk for development of delirium. The correct response identifies a patient who is likely to have tolerance to alcohol and is thus at risk for alcohol withdrawal delirium.

The nurse notes that an older patient with dementia is unable to care for self to bathe and perform other activities of daily living (ADL). Which is an appropriate goal for this patient? A. The patient will function at the highest level of independence possible B. The patient will be admitted to a long-term care facility to have ADL needs met C. The nursing staff will attend to all the patient's ADL needs during hospital stay D. The patient will complete all ADLs independently within a 1-hr time frame

All patients, regardless of age, need to be encouraged to perform at the highest level of independence possible. Independence contributes to the patient's sense of control and well-being. B is incorrect because what the self-care deficit entails is not known. To assume that the patient requires long-term care based on so little information would be erroneous. C and D use the word all and are closed-ended statements.

Which statement(s) accurately describe(s) mild cognitive impairment (MCI)? Select all that apply. A. Cannot be detected by screening tests B. The person may appear normal to the casual observer C. Family members may see changes in the patient's abilities D. Problems that the person is experiencing interfere with daily activities E. The person is usually aware that there is a problem with his or her memory

B, C, & E. The patient with MCI has problems that are severe enough to be noticed by the person having them and to others and can be found on screening tests. Family members may see changes in the person's abilities. To the casual observer, the person with MCI may seem normal. Because the problems do not interfere with daily activities, the patient does not meet the criteria for being diagnosed with dementia.

When providing community health care teaching about the early warning signs of AD, which signs should the nurse ask 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. Momentarily forgets an acquaintance's name F. Becoming lost in an usually familiar environment

B, C, D & F. 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 AD. Misplacing car keys and momentarily forgetting a name are normal frustrating events for many people.

An older female client with advanced dementia is admitted to the hospital with a fractured hip. The patient repeatedly tells the staff, "Take me home. I want my mommy." Which response is best for the nurse to provide? A. Orient the patient to time, place, and person B. Tell the patient that the nurse is there and will help her C. Remind the patient that her mother is no longer living D. Explain the seriousness of her injury and need for hospitalization

B.

The nurse is caring for an older patient following surgical repair of a hip fracture. On assessment of the patient, the nurse notes that the patient is disoriented and is attempting to get out of bed. Which is the most appropriate initial nursing intervention? A. Apply restraints to the patient B. Place a mattress sensor pad on the bed C. Have the UAP check on the patient every 30 mins D. Collaborate with the HCP for a prescription for a sedative

B. A patient should not be placed in a physical restraint or sedated just because he or she is older and disoriented. Alternative methods should be used before applying any types of restraints. For example, a mattress sensor pad will alert the nursing staff of movement. Physical restraints may cause further disorientation and should not be applied unless specifically prescribed. Agency policies and procedures should be followed before the application of restraints.

A nurse is caring for an 84-yr-old man admitted with a diagnosis of severe AD. In the admission assessment, the nurse notes that the patient can no longer recognize familiar objects such as his glasses and toothbrush. What is the best term to describe this situation? A. Apraxia B. Agnosia C. Aphasia D. Amnesia

B. Agnosia is the term used to describe the loss of sensory ability to recognize familiar sounds and objects, as well as loved ones or even parts of the affected individual's body. Amnesia is the term for the impairment of memory both recent and remote. Aphasia is the term for the loss of language ability, which progresses with the disease. Apraxia is the term for the loss of purposeful movement in the absence of motor or sensory impairment. The individual is unable to perform purposeful tasks such as walking or putting on clothing properly.

An older client in an acute state of disorientation is brought to the ED by the patient's daughter. The daughter states that the client was "clear as a bell this morning." The nurse determines from this piece of information that which is an unlikely cause of the disorientation? A. Hypoglycemia B. Alzheimier's disease C. Medication dosage error D. Impaired circulation to the brain

B. Alzheimer's disease is a chronic disease with progression of memory deficits over time. The situation presented in the question represents an acute problem. Evaluation is necessary to determine whether hypoglycemia, medication use, or impaired cerebral circulation has had a role in causing the patient's current symptoms.

An 84-yr-old tells the nurse, "I do four or five number puzzles every day to keep my brain healthy and sharp." When considering a holistic approach to maintaining mental health, the nurse should respond: A. "It is more important for you to have physical activity every day" B. "Let's think of some other activities we can add to your daily routine" C. "Repetition of the same activity is not helpful for keeping your brain healthy" D. "There are some herbal preparations that will also help keep your brain sharp"

B. Important considerations for promoting mental health in the older adult include the need for older adults to continue to include social, intellectual, and physical activity in their routine. Older adults can continue to learn and contribute even when physiological changes occur.

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.

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.

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement first? A. Move the client next to the nurses' station B. Use an indirect light source and turn off the TV C. Keep the TV and a soft light on during the night D. Play soft music during the night, and maintain a well-lit room

B. Provision of a consistent daily routine and a low-stimulating environment is important when a client is disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses' station may become necessary but is not the initial action.

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.

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.

An older female patient with AD is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response should the nurse provide? A. Anywhere you want to stand as long as you do not get hurt by those in the parade B. You are confused because of all the activity in the hall. There is no parade C. Let's go back to the activity room and see what is going on in there D. Remember I told you that this is a nursing home and I am your nurse

C.

The nurse is caring for a patient diagnosed with Alzheimer's disease (AD). The nurse should anticipate that the patient has changes in which component of the nervous system? A. Glia B. Peripheral nerves C. Neuronal dendrites D. Monoamine oxidase

C. AD is characterized by changes in the dendrites of the neurons. The decrease in the number and composition of the dendrites is responsible for the symptoms of the disease. The components in the other options are not related to the pathology of AD.

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.

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.

Dementia with Lewy bodies (DLB) is characterized by: A. remissions and exacerbations over many years B. memory impairment, muscle jerks, and blindness C. parkinsonian symptoms, including muscle rigidity D. increased intracranial pressure from decreased CSF drainage

C. DLB is characterized by features of dementia and Parkinson's disease. These patients typically have manifestations of Parkinsonism, hallucinations, short-term memory loss, unpredictable cognitive shifts, and sleep problems.

The nurse in the long-term care facility cares for a 70-yr-old man with 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. Limit fluid intake during mealtimes to prevent aspiration B. Turn on the television to provide a distraction during meals C. Provide thickened fluids and moist foods in bite-sized pieces D. Allow the patient to select favorite foods from the menu choices

C. 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 TV, should be avoided. Fluids should not be limited but offered frequently; fluids should be thickened. Patients with late-stage dementia have difficulty understanding words and would not have the cognitive ability to select menu choices.

A family member asks the nurse, "I know my uncle's Alzheimer's disease has progressed but is there any medication that can help him now?" Which response by the nurse is correct? A. "I'm sorry, but there are no medications that help with severe Alzheimer's disease" B. "Alzheimer's disease sometimes stabilizes. Let's hope that happens in this situation" C. "There are a few medications that may help. Let's discuss it with the HCP" D. "It sounds like you're having difficulty accepting that your uncle's disease is irreversible. Would you like to talk about those feelings?"

C. Memantine (Namenda), an N-methyl-d-aspartate (NMDA) antagonist, and some cholinesterase inhibitors may be prescribed to treat symptoms of moderate to severe AD.

The nurse is caring for a patient with a neurological deficit involving the hippocampus. On assessment of the client, which signs and symptoms would most likely be noted? A. Disoriented to self, place, and time B. Affect flat, with periods of emotional lability C. Cannot recall what was eaten for breakfast today D. Unable to add and subtract; does not know who is president

C. Recall of recent events and the storage of memories are controlled by the hippocampus, which is a limbic system structure. The cerebral hemispheres, with specific regional functions, control orientation. The limbic system, overall, is responsible for feelings, affect, and emotions. Calculation ability and knowledge of current events are under the control of the frontal lobes of the cerebrum.

While interacting with a 62-yr-old patient diagnosed with a progressive neurocognitive disorder, the nurse observes that the patient has slow responses and difficulty finding the right words. What is the nurse's best initial action? A. Suggest words that the adult may be trying to remember B. Ask the adult, "Are you having problems saying what you mean?" C. Use silence to allow the adult an opportunity to compose responses D. Discontinue the interaction to prevent further frustration for the patient

C. Silence is an therapeutic communication technique. It is respectful and provides an opportunity for the patient to compose responses.

A UAP working for a home care agency reports a change in the alertness and language of an 82-yr-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. The MMSE is often used 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.

A patient is diagnosed with the mild cognitive impairment (MCI) of AD. What nursing intervention is most appropriate for the nurse to use with this patient" A. Communicate using a letter or picture board B. Treat disruptive behavior with antipsychotic drugs C. Use a calendar and family pictures as memory aids D. Apply a wander guard mechanism to keep the patient in the area

C. The patient with MCI 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.

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. Vascular dementia (VaD) is the loss of cognitive function that results from ischemic, ischemic-hypoxic, or hemorrhagic brain lesions caused by cardiovascular disease (CVD). In this type of dementia, narrowing and blocking of arteries that supply the brain cause a decrease in blood supply.

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

C. 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 show respect.

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

D. An early warning sign of AD 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 manifestations of middle or moderate dementia (or AD). Incontinence and inability to perform self-care activities occur with severe or late dementia (or AD).

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. Dementia is a syndrome characterized by dysfunction in or loss of memory, orientation, attention, language, judgement, and reasoning. Personality changes and behavior problems, such as agitation, delusions, and hallucinations, may occur.

A patient with dementia and chronic confusion is suspected to have Alzheimer disease. Which imaging technique is specific for Alzheimer disease? A. Diffusion imaging (DI) B. Magnetic resonance imaging (MRI) C. Magnetic resonance angiography (MRA) D. Magnetic resonance spectroscopy (MRS)

D. In diseases such as AD, stoke, and epilepsy, the biochemical process in the brain is altered. Abnormalities in biochemical processes of the brain are diagnosed with magnetic resonance spectroscopy (MRS). Diffusion imaging (DI) is used to evaluate ischemia in the brain to determine the location and severity of a stroke. MRI involves taking multiple sets of images to determine normal and abnormal anatomy. MRA is used to evaluate blood flow and blood vessel abnormalities, such as arterial blockage, intracranial aneurysms, and arteriovenous malformations in the brain.

The nurse is developing a plan of care for a patient with a diagnosis of early-stage Alzheimer's disease. The plan of care should include nursing interventions that address which early characteristic of Alzheimer's disease? A. Confusion B. Wandering C. Frustration D. Forgetfulness that interferes with the daily routine

D. In early Alzheimer's disease, forgetfulness begins to interfere with daily routines. The patient has difficulty concentrating and difficulty learning new material. A, B, and C are characteristics of this disorder but occur later as the disease progresses.

The nurse is assessing the patient's level of consciousness and documents that the patient has delirium. On the basis of this documentation, the nurse should determine that there is damage to which area of the nervous system? A. Temporal lobe and frontal lobe B. Hippocampus and frontal lobe C. Limbic system and cerebral hemispheres D. Reticular activating system and cerebral hemispheres

D. Insomnia, agitation, mania, and delirium are caused by excessive arousal of the reticular activating system in conjunction with the cerebral hemispheres. The temporal lobe, hippocampus, and frontal lobe are responsible for memory. The limbic system is responsible for feelings and affect.

What is the priority nursing intervention for a forgetful, disoriented patient with the diagnosis of dementia of the Alzheimer type? A. Restricting gross motor activity B. Preventing further deterioration C. Keeping the patient oriented to time D. Managing the patient's unsafe behaviors

D. Patients with AD require external controls to minimize the danger of injury caused by lack of judgement. The staff should not prevent all gross motor activity; the patient needs to use the muscles, or atrophy will occur. Further deterioration usually cannot be prevented in this disorder with nursing interventions; donepezil may help delay deterioration in some patients. It may not be possible to keep the patient continuously oriented.

Which patient has the greatest risk of developing delirium? A. An older patient whose recent CT scan shows brain atrophy B. A patient with fibromyalgia whose chronic pain has worsened C. A patient with a fracture who spent the night in the emergency department D. An older patient who takes multiple medications to treat various health problems

D. 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.

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 total hysterectomy D. A 78-year old man admitted to the medical unit with complications of heart failure (HF)

D. 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 (Table 59-16).

A patient diagnosed with stage 2 AD begins a new prescription for rivastigmine (Exelon). Which nursing diagnosis has the highest priority to add to the plan of care? A. Risk for constipation B. Risk for altered sensory perception C. Risk for impaired oral mucous membranes D. Risk for imbalanced nutrition, less than body requirements

D. Side effects of rivastigmine (Exelon) include nausea, vomiting, diarrhea, weight loss, loss of appetite, and muscle weakness.

The clinical diagnosis of dementia is based on: A. CT or MRS B. brain biopsy C. electroencephalogram D. patient history and cognitive assessment

D. The diagnosis of dementia depends on determining the cause. A thorough physical assessment is done 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 on neuroimaging, and the exclusion of other causes of dementia. Structural neuroimaging with CT scan or MRI is used to evaluate patients with dementia but does not provide a definitive diagnosis. A psychologic evaluation is needed to determine the presence of depression.

The nurse is conducting a neurological assessment, including a health history, on a patient with a neurological disorder. The nurse observes that the patient is having difficulty answering the questions and should perform which action? A. Ask a second nurse to be present during the interview B. Defer both the health history and the neurological examination C. Defer the health history and proceed with the neurological examination D. Ask the patient to give permission for a family member to stay during the interview

D. The health history and physical assessment for a patient with a neurological problem are very similar to those for any other patient, with perhaps a more intense neurological examination. If the patient is confused or agitated or has difficulty hearing or speaking, the nurse should ask the patient to give permission for a family member or significant other to stay with him or her during the history taking to ensure accurate data. Deferring the health history and/or neurological examination will not obtain the assessment data. Having a second nurse present is of no benefit.

An older patient is brought to the hospital emergency department (ED) by a neighbor who heard the patient talking and found him wandering in the street at 0300. The nurse should first determine which data about the patient? A. Insurance status B. Blood toxicology levels C. Whether he ate his evening meal D. Whether this is a change in usual level of orientation

D. The nurse should first determine whether this behavior represents a change in the client's neurological status. The next item to determine is when the client last ate. Blood toxicology levels may or may not be needed, but the health care provider would likely prescribe these. Insurance information must be obtained at some point but is not the priority from a clinical care viewpoint.

An older resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." Which is the appropriate response by the nurse? A. "I need you to sign a form before leaving" B. "You will get sick if you go out in the rain" C. "How old are you? Your father must no longer be living" D. "Let's have a cup of coffee, and you can tell me about your father"

D. This response acknowledges the patient's comment and behavior. Allowing the patient to leave after forms are signed fails to protect the patient from possible harm. The remaining options do not preserve the patient's dignity.

The nurse is caring for a patient diagnosed with Alzheimer's disease who is demonstrating characteristics of agnosia. Which patient behavior supports the presence of this cognitive deficiency? A. The patient has difficulty with balance when rising from the chair B. The patient has lost the cognitive ability to fold his own clothes C. The patient recognizes his children but has difficulty calling them by name D. When asked to pick up the cup, the patient consistently fails to identify the cup

D. When illness (Alzheimer's disease) affects the temporal-parietal-occipital association cortex, the patient may experience the inability to identify well-known objects and people. This is called agnosia. Ataxia describes altered motor function. The client also may experience difficulty finding the right word to use, called aphasia, and an inability to perform familiar skilled activities, called apraxia.