MED-SURG CH. 22 EAQ

The nurse is educating care providers and family members of patients with Alzheimer disease. The nurse would emphasize information regarding which medication that is used specifically for the medical management of Alzheimer disease? 1. Donepezil 2. Haloperidol 3. Olanzapine 4. Risperidone

1. Donepezil Donepezil is a drug used in the medical management of Alzheimer disease. Haloperidol, olanzapine, and risperidone are antipsychotic drugs. Although antipsychotic medications are sometimes prescribed as well, growing evidence suggests that these drugs may increase the risk for death. They are not specifically designed for the management of Alzheimer disease.

A patient with mild cognitive impairment is having trouble remembering to take medications. What is the best suggestion the nurse could make to this patient? 1. Let a family member give the medications. 2. Advise the patient to use a medication container with daily dividers. 3. Gently inform the patient that a nursing home admission is needed. 4. Refer to a home health agency to make visits for medication administration.

2. Advise the patient to use a medication container with daily dividers. The patient can use a medication container with daily dividers to enable him or her to determine readily if the day's medications have been taken. People with mild cognitive impairment experience memory impairment but otherwise have normal cognitive function and retain the ability to perform activities of daily living. A family member, a nursing home, and a home health agency are not needed for a patient with mild cognitive impairment.

The nurse is reviewing the medication administration record and notes that the patient has an order to receive donepezil 5 mg PO every day at bedtime. The nurse knows that this patient has been diagnosed with which disorder? 1. Vascular dementia 2. Alzheimer disease 3. Huntington disease 4. Frontotemporal dementia

2. Alzheimer disease Donepezil is used for Alzheimer disease. Vascular dementia is treated with antiplatelet medications. Huntington disease is treated with antipsychotics, anticonvulsants, antidepressants, and benzodiazepines. Selective serotonin reuptake inhibitors (SSRIs) are used to treat depression associated with frontotemporal dementia.

The cognitive developmental approach (CDA) that guides the care for patients with dementia includes which aspect of care? 1. Providing total patient care 2. Recognizing irrational fears 3. Preventing wandering with physical restraint 4. Offering several choices for independent decision making

2. Recognizing irrational fears Recognizing irrational fears, such as the fear of the bathtub, and therefore arranging alternative ways to give personal care, is a CDA guideline that can direct the care for patients with dementia. Self-care should be encouraged at whatever level the patient can function. A safe environment should be created for wandering instead of trying to keep the patient from wandering. Offering limited choices helps simplify decision making.

The nurse is caring for an older adult patient who was admitted for delirium due to a urinary tract infection. Which signs and/or symptoms would the nurse expect the patient to exhibit? Select all that apply. 1. Hyperfocused 2. Slurred speech 3. Delusional thinking 4. Aimless repetition of phrases 5. Symptoms improve during the night

2. Slurred speech 3. Delusional thinking 4. Aimless repetition of phrases Common signs and symptoms of delirium include slurred speech with aimless repetition, delusional thinking, inability to focus, and symptoms that worsen at night.

A nurse is caring for an older adult postoperatively. Which symptoms does the nurse determine are more closely associated with delirium? Select all that apply. 1. Several self-care deficits 2. Slurred, rambling speech 3. Difficulty in finding proper words 4. Difficulty focusing, easily distracted 5. Rapid onset of symptoms, often at night

2. Slurred, rambling speech 4. Difficulty focusing, easily distracted 5. Rapid onset of symptoms, often at night The onset of delirium is usually rapid, mostly at night, and with abrupt progression. The person experiencing delirium may have difficulty focusing and is easily distraction. The speech is often slurred and rambling. In contrast, dementia has a slow onset and progression. The changes are subtle and progress over many years. As the cognitive decline progresses, and more brain areas are affected, the patient may have difficulty in finding proper words and participating in self-care.

A patient with dementia is refusing to take a bath and is becoming more agitated. Which is the best action for the nurse to take? 1. Make the patient take a bath. 2. Try a different approach later. 3. Call a family member to give the bath. 4. Have unlicensed assistive personnel (UAP) help give the bath.

2. Try a different approach later. When patients resist activities such as bathing or dressing, avoid confrontations, which only provoke agitation and possible violence. Instead, come back at another time. Making the patient take a bath, calling a family member, or having the UAP and the nurse give the bath can aggravate the problem.

An older adult with a history of multiple infarctions of the cortex is undergoing treatment in a long-term care facility. Which disease is the patient most at risk of developing? 1. Delirium 2. Vascular dementia 3. Alzheimer's disease 4. Mild cognitive impairment

2. Vascular dementia Vascular dementia is a loss of cognitive functioning resulting from ischemic or hemorrhagic brain lesions caused by cardiovascular disease. This type of dementia is the result of decreased blood supply from narrowed and blocked arteries that supply oxygen to the brain. Alzheimer's disease is a neurodegenerative disease, and cardiac arrhythmia is not related to its pathogenesis. Mild cognitive impairment is a nonspecific symptom of various types of dementia, and although it is the second stage of the Alzheimer's spectrum, it is a symptom (not a disease) and is not correlated specifically with cardiac arrhythmia. Being of advanced age, this patient is at risk of delirium; however, delirium may not be directly caused by an infarction of the cortex.

Which information should the nurse keep in mind when caring for a patient with dementia? Select all that apply. 1. Patients with dementia need several choices at a time. 2. Patients with dementia need higher levels of stimulation. 3. Patients with dementia like different caregivers each day. 4. Patients with dementia usually forget things relatively quickly. 5. Patients with dementia are usually unable to learn new things.

4. Patients with dementia usually forget things relatively quickly. 5. Patients with dementia are usually unable to learn new things. Two important concepts are helpful to keep in mind when taking care of patients with dementia: (1) they usually forget things relatively quickly, and (2) they are usually unable to learn new things. Patients with dementia do not tolerate several choices well. Patients with dementia need lower levels of stimulation and require the same caregivers to provide security.

How should the nurse prepare the room for a patient with delirium? 1. Keep the room dark. 2. Use a semiprivate room. 3. Turn the television and radio on. 4. Place clocks and calendars in the room.

4. Place clocks and calendars in the room. Familiar objects such as pictures, a clock, and a large calendar placed in the room can help orient the patient to time and place. Lighting should be soft and diffuse to avoid shadows that may be misinterpreted and add to the patient's fears. If possible, keep the patient in a private room with continual supervision. Keep the room quiet and uncluttered to avoid agitation caused by extraneous stimuli.

A patient with dementia has started to wander outside and can unlock the doors. Which action can the nurse recommend be added to the care plan? 1. Restrain the patient. 2. Place the bed in high position. 3. Allow the patient to walk unassisted. 4. Place new door locks in a different place.

4. Place new door locks in a different place. Take advantage of the fact that patients with dementia are usually slow or unable to learn new things. For example, putting new locks on the doors in new places may prevent wandering patients from opening exit doors. Avoid the use of restraints. Place the bed in the low position. The patient should be supervised when walking.

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Which are the two major types of confusion? 1. Delirium and dementia 2. Chronic confusion and dementia 3. Psychosis and acute confusional states 4. Alzheimer's disease and chronic confusion

1. Delirium and dementia The two major types of confusion are (1) acute confusional states or delirium and (2) chronic confusion or dementia. Chronic confusion and dementia are the same type of confusional state. Psychosis can be classified under delirium, which is an acute confusional state. Alzheimer disease is a subcategory of chronic confusion.

The nurse is assigned to care for a patient with dementia. Which is the priority nursing intervention at this time? 1. Meet basic needs 2. Meet family needs 3. Meet spiritual needs 4. Meet emotional needs

1. Meet basic needs The first priority for patients with dementia is to meet their basic needs. Family, spiritual, and emotional needs are secondary to basic needs.

A patient with delirium is continually pulling on the intravenous (IV) tube. Which action should the nurse take? 1. Position the tube out of sight. 2. Gently restrain the arm to the bed frame. 3. Repeatedly ask the patient to leave the tubes alone. 4. Ask a family member to hold down the patient's arm.

1. Position the tube out of sight. The patient with delirium may pull on tubes. Position the tubes out of sight. Avoid physical restraints, which tend to increase anxiety and agitation in confused patients. Repeatedly asking the patient to leave the tubes alone can increase agitation. Although asking a family member to stay in the room with the patient can be helpful, the family member should not restrain the patient's arm.

The plan of care for a patient with dementia is to use CDA. The nurse knows that which protocol will the staff utilize in the plan of care for this patient? 1. The Cognitive Developmental Approach 2. The Caring for Dementia Alzheimer's Protocol 3. The Certified Dementia Association Guidelines 4. The Client's Guide to Dealing with Altered Cognition

1. The Cognitive Developmental Approach One approach that can also guide care for patients with dementia is the Cognitive Developmental Approach (CDA), which adapts interventions based on the patient's cognitive abilities. CDA does not stand for the Caring for Dementia Alzheimer's Protocol, Certified Dementia Association Guidelines, or Client's Guide to Dealing with Altered Cognition.

The nurse is caring for a patient who appears alert and oriented. After the administration of his diazepam, the patient becomes confused and agitated. What is the reason for the patient's change of orientation? 1. The patient is exhibiting drug-induced delirium from diazepam 2. The patient is exhibiting signs of Alzheimer's disease 3. The patient is exhibiting signs of Parkinson disease 4. The patient is exhibiting Lewy body disease

1. The patient is exhibiting drug-induced delirium from diazepam The patient is exhibiting delirium after the administration of diazepam. The patient is not exhibiting signs of Alzheimer's disease, Parkinson's disease, or Lewy body disease

The nurse is caring for a patient who has recently been diagnosed with delirium. Which information provided by the patient's husband is most closely correlated with this diagnosis? 1. "The health care provider says she will most likely never improve." 2. " She suddenly started crying uncontrollably when she had a bladder infection." 3. "At first, she kept misplacing her keys. As months passed, the memory loss became more noticeable." 4. "She has had trouble remembering new acquaintances for ages. Now, she doesn't recognize me, either."

2. " She suddenly started crying uncontrollably when she had a bladder infection." Delirium is characterized by sudden onset confusion that can resolve if the causative factor is fixed. Dementia is characterized by chronic confusion that has worsened over time and does not improve. The nurse would expect the husband to report that the patient suddenly exhibited symptoms associated with a bladder infection. A patient with dementia will most likely never improve. Dementia first impairs short-term memory creation, as with meeting new acquaintances or locating keys, and then affects long-term memory as the disease progresses.

The nurse is reinforcing teaching about medications for Alzheimer dementia (AD) to a family member. Which information by the family member indicates that more teaching is needed? 1. "These drugs include donepezil and rivastigmine " 2. "These drugs if taken long enough will cure the disease." 3. "These drugs work by increasing acetylcholine in the brain." 4. "These drugs are most effective in the early to middle stages."

2. "These drugs if taken long enough will cure the disease." None of the AD drugs is curative, and eventually the patient will decline despite drug therapy. Most act to increase the amount of acetylcholine in the brain. They are most effective in the early to middle stages of AD. These types of drugs include donepezil, rivastigmine, and galantamine.

A patient is admitted to an acute care facility with the diagnosis of vascular dementia. Patients with vascular dementia often have had which disorder? 1. Brain tumors 2. Diabetes mellitus 3. Open heart surgery 4. A series of small strokes

4. A series of small strokes Often patients with vascular dementia have had a series of small strokes that cause progressive damage. Brain tumors, diabetes mellitus, and open heart surgery do not cause vascular dementia.

The nurse is participating in a family teaching session for a patient with dementia. Family members will be caring for the patient at home. The nurse knows that the family understands the instructions if they identify which aspect as the priority of care? 1. Provide constant reality orientation. 2. Meet the basic needs of the patient. 3. Assist the patient with nutritional needs. 4. Confront the patient when inappropriate behaviors occur.

2. Meet the basic needs of the patient. The first priority for patients with dementia is to meet their basic needs because they may not be able to meet their own needs. Whereas constant reality orientation is helpful for the patient with delirium, such orientation is not effective for the patient with dementia. Patients with dementia may eventually need help with eating. Although assisting the patient with nutritional needs is an intervention for the patient with dementia, it is not considered the priority. Confrontations only provoke agitation and possible violence

The nurse is educating the daughter of an older adult patient who was diagnosed with delirium. Which statement made by the daughter indicates a need for further teaching? 1. "My mother is likely to have symptoms that are worse at night." 2. "It is possible my mother will also experience depression and anxiety." 3. "Regardless of the treatment, my mother's mental status will not improve." 4. "My mother may experience difficulties understanding her environment."

3. "Regardless of the treatment, my mother's mental status will not improve." If the cause of the patient's delirium is determined and resolved, the patient will most likely experience a resolution of the delirium as well. Symptoms that worsen at night, depression and anxiety, and difficulties processing one's environment are all characteristic of delirium.

A patient has dementia, and the health care provider has prescribed a bulk-forming softener for constipation. Which is the priority data collection for the nurse to monitor? 1. Mental status 2. Physical stamina 3. Adequate fluid intake 4. Vital signs, especially pulse rate

3. Adequate fluid intake Bulk-forming softeners can actually cause impaction if the patient cannot take adequate fluids. Mental status, physical stamina, and vital signs will not affect the results of the bulk-forming softener like fluid will.

The family member discusses a variety of difficulties a patient is having while living at home. Which symptom or behavior correlates closest with that of Alzheimer's disease? 1. Onset within the past few weeks 2. Frequent visual hallucination of spiders 3. Decline in functioning ability over 2 years 4. Misinterpretation of slammed door as a bomb

3. Decline in functioning ability over 2 years A patient with Alzheimer's disease usually displays a decline in function over a longer period of time. A patient with delirium has symptoms which begin abruptly, is likely to have specific visual hallucinations, and misinterprets what is happening in the environment.

The nurse is caring for a patient who was diagnosed with vascular dementia. The nurse understands that the patient has likely also experienced which condition? 1. Hip fracture 2. Tertiary syphilis 3. Massive myocardial infarction 4. Progressive damage from several small strokes

4. Progressive damage from several small strokes Vascular damage is caused by progressive damage from a series of small strokes. It is possible that the patient experienced these small strokes due to fat emboli from a hip fracture or thrombi from the myocardial infarction, but there could be other causes of the strokes. Neurosyphilis causes dementia, but not vascular dementia.

The LPN is caring for a patient who is hallucinating after undergoing anesthesia. The patient tells the nurse, "I know you—you're here to kill me!" Which is the nurse's best response? 1. "What has your doctor told you about where you are?" 2. "Would you like me to find your family members now?" 3. "Perhaps you'd like some medication to calm you down." 4. "You are safe in the hospital. I am your nurse and here to help you."

4. "You are safe in the hospital. I am your nurse and here to help you." The best response is to orient the patient to the reality of being sick and hospitalized and to explain that the hallucinations are not real, although they seem to be. The phrases, "What has your doctor told you about where you are?," "Would you like me to find your family members now?," and "Perhaps you'd like some medication to calm you down," do not orient to the patient to the surroundings or to who the nurse is.

Which statement by the patient is covered under the patient Self-Determination Act? Select all that apply. 1. "I can decide to have a no code." 2. "I can determine the type of medical care I will receive at the end of life." 3. "I cannot determine what comfort measures the nurses will use during my care." 4. "I'm worried my adult children will attempt to keep me alive longer than I want to." 5. "I can decide not to have a feeding tube placed if I have a stroke and will be in a vegetative state." 6. "I can appoint a durable power of attorney for health care to make all end-of-life decisions for me if I am unable to do so."

1. "I can decide to have a no code." 2. "I can determine the type of medical care I will receive at the end of life." 5. "I can decide not to have a feeding tube placed if I have a stroke and will be in a vegetative state." 6. "I can appoint a durable power of attorney for health care to make all end-of-life decisions for me if I am unable to do so." The right to decide to accept or refuse treatment allows the patient to make decisions concerning care and treatment. Advance directives are the person's wishes regarding medical care, which would include code status, comfort measures, medical care, how they want to be treated, name of person who will make decisions if the patient is unable to do so, and what information the patient wants the family to know. The wishes of the patient should be honored. This act does not allow adult children to make decisions concerning care and treatment, unless addressed in the durable power of attorney prepared by the patient.

Which communication technique should the nurse use when dealing with a patient with delirium? 1. "It is now breakfast time." 2. "When would you like to eat?" 3. "Here are three choices; take your pick." 4. "I can't believe you think I would try to hurt you."

1. "It is now breakfast time." Simple, direct statements, such as "Now it is time to eat," are better than questions such as, "When would you like to eat?" Keep choices to a minimum. All communication and nursing care should be carried out in a way that conveys respect and preserves the patient's dignity.

The nurse is contributing to the data collection for a patient admitted with a diagnosis of delirium. The patient is actively participating in the interview and can state her name. She also reports that the date is 15 years earlier than it actually is and that she is in her home instead of the hospital. How would the nurse report this patient's orientation status? 1. Alert and Oriented x 1 2. Alert and Oriented x 3 3. Obtunded and Oriented x 1 4. Obtunded and Oriented x 2

1. Alert and Oriented x 1 The patient is alert because she is participating in the interview. Obtunded refers to a mental state that is less than fully alert. Orientation is measured in terms of the patient's ability to recall person, place, and time. The patient is oriented to person, but is not oriented to place or time. Therefore, the nurse should chart this patient's orientation status as "alert and oriented x 1". A person who is "alert and oriented x 3" would be fully alert and able to report the correct name, location, and date. A person who is "obtunded and oriented x 1" would have a decreased level of consciousness and would only be able to report one of these: person, place, or time. "Oriented x 2" would indicate an ability to report two of these: person, place, or time.

The nurse is caring for a patient with Alzheimer's disease. Which pathophysiologic proteins are associated with Alzheimer's disease? Select all that apply. 1. Amyloid 2. Pick bodies 3. α-Synuclein 4. Tau protein 5. Prion protein

1. Amyloid 4. Tau protein Amyloid and tau proteins are associated with Alzheimer's disease. Pick bodies, α-Synuclein, and prion proteins are not the proteins associated with Alzheimer's disease.

The nurse is assisting with data collection for a patient at a long-term care facility. Which features, if found, would alert the nurse to a possible diagnosis of dementia? 1. Apathetic and uninterested 2. Clearly defined hallucinations 3. Dementia duration of weeks to months 4. Affect indicating intermittent fear or bewilderment

1. Apathetic and uninterested A clinical feature of dementia is an apathetic and uninterested affect. Dementia's duration would be in progress at least 1 to 2 years, as opposed to weeks or months. Hallucinations in the patient with dementia are vague, fleeting, and ill-defined. Hallucinations are clearly defined with delirium. Affect indicating intermittent fear or bewilderment is a clinical feature of delirium.

The LPN is caring for a patient who is confused. An intravenous (IV) infusion has been prescribed. The patient tells the nurse, "I'm scared to stay here by myself!" Which nursing action is most appropriate? 1. Ask a family member to stay in the patient's room. 2. Explain to the patient why the IV infusion is necessary. 3. Administer a sedative medication as needed until the patient is calm. 4. Request an order from the health care provider for physical restraints.

1. Ask a family member to stay in the patient's room. Asking a family member to stay with the patient would most effectively address the patient's fear of being in the room alone. Explaining why the IV infusion is necessary does not address the patient's fear of being alone in the room. Administering a sedative does not address the patient's fear of being alone in the room. Using physical restraints should be avoided, as they tend to increase anxiety and agitation in the confused patient and often result in injuries.

A patient with dementia is able to dress himself. Which actions should the nurse take to help this patient get dressed? Select all that apply. 1. Break the task into steps. 2. Praise each task completed. 3. Tell the patient to get dressed. 4. Have the CNA dress the patient. 5. Allow time for the patient to dress himself.

1. Break the task into steps. 2. Praise each task completed. 5. Allow time for the patient to dress himself. Instead of instructing the patient to get dressed, first direct him to put on underclothes, then socks, pants, shirts, belt, and shoes (break the task into steps). Allow time for the patient to complete each step before giving another direction. Praise the completion of each task. Having the CNA dress the patient does not allow for the patient to function at the highest level.

Which are considered to be systemic causes of delirium? Select all that apply. 1. Burns 2. Alcohol 3. Meningitis 4. Pneumonia 5. Urinary tract infection

1. Burns 2. Alcohol 4. Pneumonia 5. Urinary tract infection Burns, alcohol, pneumonia, and urinary tract infections are considered to be systemic causes of delirium. Meningitis is considered a central nervous system cause of delirium.

Which is the term that describes a short-term confused state that has a sudden onset and is typically reversible? 1. Delirium 2. Dementia 3. Chronic confusion 4. Organic brain syndrome

1. Delirium Delirium is a short-term confused state that has a sudden onset and is typically reversible. Chronic confusion is generally considered irreversible. Dementia is another term for chronic confusion and is generally considered irreversible. Organic brain syndrome is an older term for dementia.

A patient admitted to the hospital is diagnosed with Alzheimer's disease. What drug therapy should the nurse expect the health care provider to prescribe for this patient? Select all that apply. 1. Donepezil 2. Memantine 3. Haloperidol 4. Rivastigmine 5. Risperidone

1. Donepezil 2. Memantine 4. Rivastigmine The use of drugs for Alzheimer's disease helps to reduce the rate of decline in cognitive function. Donepezil and rivastigmine are cholinesterase inhibitors. They block cholinesterase, the enzyme responsible for the breakdown of acetylcholine in the synaptic cleft. Memantine protects the brain's nerve cells against excessive amounts of glutamate, which is released in large amounts by cells damaged in Alzheimer's disease. Haloperidol and risperidone are antipsychotic drugs that are not indicated for the treatment of Alzheimer's disease; however, they can be used with caution for treating behavioral problems associated with the disease.

An older adult patient with delirium is severely agitated and becoming a danger to self and possibly others. The nurse notifies the health care provider. Which health care provider's prescription should the nurse question? 1. Give diazepam 2. Give quetiapine 3. Give haloperidol 4. Give risperidone

1. Give diazepam Benzodiazepines (diazepam) should be avoided in older adults because they are more likely to cause oversedation or worsen confusion. If the patient is so severely agitated that essential care cannot be given or the patient poses a danger to self or others, an antipsychotic drug may be ordered. Examples of antipsychotic drugs are haloperidol (Haldol), quetiapine, risperidone , and olanzapine.

The nurse is caring for a patient with delirium. Which findings will the nurse typically observe upon data collection? Select all that apply. 1. Hallucinations 2. Easily distracted 3. Disjointed speech 4. Impaired recent memory 5. Progressive declining cognitive functioning

1. Hallucinations 2. Easily distracted 3. Disjointed speech 4. Impaired recent memory Patients with delirium experience hallucinations and are easily distracted. They have disjointed speech and impaired recent memory. Progressive declining cognitive functioning is typical in dementia, not delirium.

A patient diagnosed with Alzheimer disease is prescribed donepezil. What is the purpose of this medication? 1. Increases the amount of acetylcholine in the brain. 2. Dissolves the amyloid plaques in the brain tissue. 3. Treats the associated depression the patient experiences. 4. Reverses the progression of the stages of Alzheimer's disease.

1. Increases the amount of acetylcholine in the brain. Donepezil is a cholinesterase inhibitor medication. This medication slows the breakdown of acetylcholine, a neurotransmitter in the brain, and possibly slows the rate of cognitive decline. There is no effect on the plaques of amyloid occurring in the brain with aging. There are more of these plaques in persons with Alzheimer disease. The medication does not treat depression or reverse or cure Alzheimer disease.

A patient is hospitalized with delirium and is experiencing frightening hallucinations causing him to strike out and cry. Which is the nurse's best intervention? 1. Orient the patient to reality. 2. Immediately medicate the patient as ordered. 3. Provide a few different choices of alternative activities. 4. Apply physical restraints, and notify the health care provider.

1. Orient the patient to reality. Patients with delirium may have frightening hallucinations that cause them to strike out, cry, or scream. The best response is to orient the patient to the reality of being sick and hospitalized and to explain that the hallucinations are not real although they seem to be. Medicating is not appropriate at this time because the patient needs to be assured that the medical and nursing staff are helping and keeping him or her safe. Choices should be kept to a minimum. Applying physical restraints is not appropriate at this time because the patient needs to be assured that the medical and nursing staff are helping and keeping him or her safe.

A patient with Alzheimer disease presents with increased vocalization and agitation. The nurse should further investigate for which possible cause of the symptoms? 1. Pain 2. Glaucoma 3. Schizophrenia 4. Need for restraint application

1. Pain Patients with Alzheimer disease have cognitive impairment that may affect their oral and written language. As a result, Alzheimer's disease patients may have difficulty in expressing physical complaints, including pain. The nurse should observe for signs of pain, such as increased vocalization, agitation, withdrawal, and changes in function. Pain should be recognized and treated promptly and the patient's response monitored. Vocalization and agitation are not indication for restraint use, and restraints should be avoided. Glaucoma and schizophrenia do not usually present as agitation and increased vocalization.

A patient with dementia has a disturbed sleep pattern. Which actions should the nurse take? Select all that apply. 1. Play music. 2. Sing to the patient. 3. Provide a comfort object. 4. Plan naps during the day. 5. Maximize activities late in the day.

1. Play music. 2. Sing to the patient. 3. Provide a comfort object. For a disturbed sleep pattern in a patient with dementia, music may be soothing; try singing to the patient, and provide a comfort object like a doll or blanket. Naps are discouraged, as keeping a patient awake during the day will help him or her sleep at night. Activities should be minimized, not maximized, late in the day to allow patients to "wind down" by bedtime.

The nurse is caring for a patient with dementia who has become increasingly agitated over the past 12 hours. Diversionary activities, pain medication, snacks, and toileting attempts have not helped relieve the patient's agitation. Which action should the nurse take first? 1. Nothing, the patient is just overtired 2. Assess the patient for urinary retention 3. Request a PRN dose of an antipsychotic medication 4. Request an order for blood culture and sensitivity test

2. Assess the patient for urinary retention The nurse should first assess the patient for urinary retention, as this can be a cause of increased agitation in individuals with dementia. This is the best first choice because it is noninvasive and the nurse does not need a health care provider's order to do it. It may be appropriate to request various diagnostic tests, including blood culture and sensitivity test, if the nurse is unable to determine the cause of the agitation. Additionally, if the patient continues to be agitated and is in danger of harming themselves, a PRN dose of antipsychotic medication may be necessary. It is not appropriate to ignore the patient's agitation as it could be caused by a serious physiological condition.

In 1968, the Harvard Medical School faculty developed criteria to determine the permanently nonfunctioning brain. Which function must the physician evaluate to determine permanent nonfunctioning brain death? Select all that apply. 1. Apnea 2. Complete absence of spontaneous movement and breathing 3. Lack of circulation to the brain for 24 hours as identified by technology 4. Unresponsiveness to external stimulation that normally would be painful 5. A flat electroencephalogram (EEG) for 48 hours, which indicates no electrical activity in the brain 6. Total lack of reflexes that are normally found on a neurological examination, particularly the reaction of the pupils to light

2. Complete absence of spontaneous movement and breathing 3. Lack of circulation to the brain for 24 hours as identified by technology 4. Unresponsiveness to external stimulation that normally would be painful 5. A flat electroencephalogram (EEG) for 48 hours, which indicates no electrical activity in the brain 6. Total lack of reflexes that are normally found on a neurological examination, particularly the reaction of the pupils to light All of the following are criteria for determining permanent nonfunctioning brain death: complete absence of spontaneous movement and breathing; lack of circulation to the brain for 24 hours as identified by technology; unresponsiveness to external stimulation that normally would be painful; a flat electroencephalogram (EEG) for 24 hours, which indicates no electrical activity in the brain; and a total lack of reflexes that are normally found on a neurological examination, particularly the reaction of the pupils to light. Respirations cease first, followed by the heartbeat stopping in a few minutes. Apnea only is not a diagnosis of death.

A patient who is allergic to milk and has delirium is having problems sleeping, even after a back massage. Which action should the nurse take next? 1. Offer a glass of warm milk. 2. Converse with the patient. 3. Schedule treatments right before bedtime. 4. Take the patient to the bathroom 2 hours after sleeping.

2. Converse with the patient. A soothing conversation may help the patient relax and fall asleep. Offering a warm glass of milk is contraindicated as the patient is allergic to milk. Scheduling treatments right before bedtime and taking the patient to the bathroom 2 hours after sleeping will disrupt sleep and is not indicated.

Select the appropriate manner to interact with a patient aged 75, who recently became confused and agitated in the intensive care unit. Select all that apply. 1. Correct any misstatements made by the patient. 2. Have a calm and reassuring approach with the patient. 3. Turn the television on in the room to distract the patient. 4. Make sure the patient is wearing own eyeglasses and hearing aids. 5. Reorient the patient and have clock and calendar visible to the patient.

2. Have a calm and reassuring approach with the patient. 4. Make sure the patient is wearing own eyeglasses and hearing aids. 5. Reorient the patient and have clock and calendar visible to the patient. The patient has developed delirium, which is common among older adult patients in intensive care units. A calm, reassuring approach enhances a feeling of security. Wearing eyeglasses and hearing aids assists the patient in communication. Reorientation verbally with reinforcement visuals such as a clock is helpful. Correcting all misstatements interferes with patient trust. The environment should not be overstimulating, so the television should be off.

The nurse is attempting to turn a patient who is experiencing delirium. The patient begins to strike out, thrash, and scream that a monster is attacking him. What should be the nurse's priority intervention? 1. Call for help. 2. Make the patient's surroundings as safe as possible. 3. Step out of the room; the patient clearly does not want to be turned. 4. Tell the patient that he is in a safe place and that the monster isn't real.

2. Make the patient's surroundings as safe as possible. If the patient begins to thrash and strike out, the nurse should first lower the bed to the lowest setting, remove all objects that the patient could pull onto himself, and ensure that the patient does not hurt himself or others. Once the surroundings are safe, the nurse should attempt to reorient the patient by identifying herself to the patient and telling the patient that he is ill and in the hospital, and that there are no monsters. If the patient does not calm down, the nurse may need to call for help. It is inappropriate to step out of the room until the patient has calmed down and is no longer in immediate danger of harming himself.

Which type of schedule is best for the nurse to maintain for a patient with dementia? 1. One with continual input of stimuli 2. One that is consistent with the same caregiver 3. One that rotates activities to decrease the chance for boredom 4. One that provides opportunities for multiple choices to make decisions

2. One that is consistent with the same caregiver A consistent schedule of care given by the same caregiver provides security for the patient with dementia. Patients with dementia need consistency and continual input of stimuli. Rotation of activities and providing opportunities for multiple choices do not provide consistency and would be detrimental for the patient with dementia.

A patient suddenly develops confusion and disorientation. Which is the nurse's priority action? 1. Decrease pain 2. Provide safety 3. Increase anxiety 4. Promote nutrition

2. Provide safety During an episode of confusion, focus attention on supporting the patient to provide safety and comfort and to reduce anxiety. Decreasing pain and promoting nutrition are not priority; these can be addressed after safety is provided. Increasing anxiety will make the situation worse; reducing anxiety is needed.

Which statement is correct about the difference between delirium and dementia? 1. Delirium has fluctuating and depressed moods; dementia's moods are labile and suspicious. 2. Dementia's perceptions include possible visual, auditory, and tactile hallucinations; delirium's perceptions may have hallucinations and delusions. 3. Delirium has a sudden onset, lasts hours to days, and thought processes are fragmented; dementia's onset takes months to years, can last long term or a lifetime, and thought processes are impaired. 4. Dementia has a sudden onset, lasts hours to days, and thought processes are fragmented; delirium's onset takes months to years, can last long term or a lifetime, and thought processes are impaired.

3. Delirium has a sudden onset, lasts hours to days, and thought processes are fragmented; dementia's onset takes months to years, can last long term or a lifetime, and thought processes are impaired. Delirium has a sudden onset, lasts hours to days, and thought processes are fragmented; dementia's onset takes months to years, can last long term or a lifetime, and thought processes are impaired. Dementia has fluctuating and depressed moods; delirium's moods are labile and suspicious. Delirium's perceptions include possible visual, auditory, and tactile hallucinations; dementia's perceptions may have hallucinations and delusions.

Which professionals have a high risk of developing delirium due to an increased incidence of head trauma? Select all that apply. 1. Fishermen 2. Tennis players 3. Football players 4. Military members 5. Race car drivers

3. Football players 4. Military members 5. Race car drivers Head trauma is a risk factor for delirium. Football players, military members, and race car drivers are at elevated risk of getting injured and eventually developing delirium. Tennis players and fishermen have a low risk of head trauma and therefore are at low risk of developing delirium related to their profession.

Physical assessment: Disoriented to time and place, oriented to name, vitals stable, short-term memory intact Health History: Anxiety and forgetfullness began 2 days ago, history of ulcers and heart failure, and has trouble sleeping Medications: Digoxin and diazepam After reviewing the chart, determine which finding helps the nurse establish the cause of the patient's confusion? 1. Trouble sleeping 2. History of ulcers 3. Medications currently being taken 4. Disorientation to time and place

3. Medications currently being taken Medications that most often cause confusion include anticholinergic drugs, digoxin, H2-receptor blockers, benzodiazepines , nonsteroidal antiinflammatory drugs, and many antidysrhythmic and antihypertensive drugs. Trouble sleeping, history of ulcers, and disorientation to time and place do not help determine the cause of the confusion. Trouble sleeping and disorientation are signs and symptoms of confusion, not the cause.

The nurse is caring for a 70-year-old patient. What are the symptoms of dementia that the nurse should be observant for? Select all that apply. 1. Seizures 2. Dyspnea 3. Memory loss 4. Impaired problem-solving ability 5. Progressive dependence on others

3. Memory loss 4. Impaired problem-solving ability 5. Progressive dependence on others In dementia, there is progressive neurodegeneration, and vascular changes lead to cognitive impairment. The cognitive impairment manifests as progressive dependence on others, memory loss, and impaired problem-solving ability which are all symptoms of dementia. Other symptoms include dysfunction or loss of orientation, attention, language, judgment, and reasoning. Presence of seizures indicates other neurologic problems. Dyspnea is a manifestation of impaired respiratory function.

A patient with dementia forgets to eat, can use hands and fingers but cannot use utensils, and is full after several bites. How can the nurse improve this patient's nutritional status? 1. Let the patient eat in a private room. 2. Offer finger foods that are low in protein. 3. Offer small, frequent meals throughout the day. 4. Let the patient use assistive devices, such as a large fork or spoon.

3. Offer small, frequent meals throughout the day. Because of the patient's short attention span, he or she may actually consume more food if given small, frequent meals. Group meals may be helpful because patients often imitate the behaviors of others. Finger foods would be good for this patient, but the foods need to be high (not low) in protein and carbohydrates. The patient cannot use utensils, so letting the patient use assistive devices is counterproductive.

The LPN is caring for a patient with dementia who is losing weight and has stopped eating most meals. When the LPN assesses the patient's ability to self-feed, the patient tells her, "I just don't know what to do." Which is the most appropriate intervention? 1. Turn the television on in the dining room to distract the patient. 2. Frequently remind the patient which utensil to use and what to eat at what time. 3. Provide the patient with a spoon, and serve high-protein and carbohydrate items. 4. Delegate to a CNA the task of feeding meals to the patient, and then monitor intake.

3. Provide the patient with a spoon, and serve high-protein and carbohydrate items. Offering the patient only one utensil may help the patient self-feed. The dining area should be free from distractions. Frequently reminding the patient which utensil to use and what to eat at what time will diminish the patient's remaining ability to make choices for himself. Encouraging self-care at whatever level the patient can function is important.

The patient with dementia is prescribed memantine. The nurse knows that the medication was prescribed for which reason? 1. Stop agitation 2. Slow depression 3. Treat late stage dementia 4. Inhibit the enzyme, cholinesterase

3. Treat late stage dementia Memantine (Namenda) is prescribed for mid to late stage dementia. It does not have any antidepressive components or help with agitation. It does not have any effect on inhibiting cholinesterase.

The LPN/LVN is supervising the care of a patient with acute confusion. Which action by the unlicensed assistive personnel (UAP) would prompt the LPN/LVN to intervene? 1. Putting on the patient's glasses so the patient can see 2. Putting in the patient's hearing aids so the patient can hear 3. Turning off all the lights in the patient's room so the patient can sleep 4. Placing the patient's clock in a prominent position so the patient knows what time it is

3. Turning off all the lights in the patient's room so the patient can sleep The nurse should intervene if the UAP turns off all the lights in the patient's room. The UAP should leave on a night light or some other soft, diffuse light to decrease the shadows in the room. The patient will likely be afraid of the dark. If the patient requires glasses and/or hearing aids, they should be on whenever the patient is awake. Additionally, clocks, pictures, and calendars should be placed near the patient to help orient the patient to person and time.

The LPN is assisting with data collection for a new patient who is found to be confused. Which is the best way for the nurse to determine the confusional state of the patient? 1. Read the patient's chart. 2. Talk with family members. 3. Ask the patient why he is here. 4. Observe the patient's behavior.

4. Observe the patient's behavior. The first step in assessing a confusional state is to observe the patient's behavior and to evaluate orientation, memory, and sleep habits. Reading the patient's chart, talking with family members, and asking the patient why he or she is here would be less helpful in determining the patient's behavior.

A patient with delirium is having hallucinations of being violently killed. What is the nurse's best response? 1. "You are just seeing things. There's nothing to worry about." 2. "Tell me how you are going to be killed. I am interested in you." 3. "We are here to help you. You shouldn't be afraid of us; we like you." 4. "You are sick in the hospital, and what you are seeing is part of the illness."

4. "You are sick in the hospital, and what you are seeing is part of the illness." The best response is to orient the patient to the reality of being sick and hospitalized and to explain that the hallucinations are not real even though they seem to be. You might say, "You are sick in the hospital, and what you are seeing is part of the Illness." The patient needs to be assured that the medical and nursing staff are able to keep the patient safe. Telling the patient there is nothing to worry about, or discounting fear and urging the patient to talk about how the killing will take place are not therapeutic interventions.

Which patient description best depicts a patient with delirium? 1. A patient with chronic confusion 2. A patient with many cognitive deficits 3. A patient who has irreversible confusion 4. A patient who suddenly became confused

4. A patient who suddenly became confused Delirium is a short-term confused state that has a sudden onset and is typically reversible. Dementia is a syndrome that is chronic and generally considered irreversible and is characterized by impairment in memory accompanied by many other cognitive deficits.

Which patient will benefit the most from the nurse using constant reality orientation? 1. A patient with Alzheimer disease 2. A patient with continued decline of mental function 3. A patient with chronic dementia and impaired hearing 4. A patient with acute onset of confusion from an infection

4. A patient with acute onset of confusion from an infection Whereas constant reality orientation is helpful for the patient with delirium, such orientation is not effective for the patient with dementia. Delirium is a sudden (acute) onset of confusion from an infection. A patient with Alzheimer disease and one with continued decline of mental functioning are examples of dementia.

The nurse is working in a long-term care facility for patients with dementia that utilizes the cognitive developmental approach (CDA) to guide care. Which situation exemplifies the principles of CDA? 1. Regardless of mental capacity, the patient is an adult and care should be directed as such. 2. Recognize the patient's fear of the bathtub as irrational and give tub baths as quickly and efficiently as possible. 3. Realize that the patient can no longer perform activities of daily living independently and have the staff perform them completely. 4. Accept that a patient is going to wander and create a safe environment for the patient to do so.

4. Accept that a patient is going to wander and create a safe environment for the patient to do so. The cognitive developmental approach (CDA) adapts nursing care based on each individual's cognitive abilities. The staff should accept that the patient is going to wander and make it safe for the patient to wander rather than attempting to prevent the patient from wandering. It can be helpful to use strategies that often work with children with adults with advanced dementia. Patients with dementia can have many irrational fears, one of which is a fear of the bathtub. That fear should be respected and alternative bathing methods employed. Although patients may not be able to perform activities of daily living independently, self-care should be encouraged as much as possible.

The nurse is assisting with activities of daily living (ADLs) for a patient with moderate dementia. What is the best way for the nurse to maximize functional ability during oral care? 1. Repeatedly tell the patient to brush his teeth. 2. Brush the patient's teeth without the patient's assistance. 3. Have the patient hold the tube of toothpaste to keep him occupied. 4. Break the task of brushing the patient's teeth into more manageable tasks.

4. Break the task of brushing the patient's teeth into more manageable tasks. A patient with moderate dementia may be able to independently perform small tasks with supervision and direction. Instead of repeatedly reminding the patient to brush the teeth, the nurse should break down the multistep task of brushing the teeth into parts.

The licensed practical nurse (LPN) hears the certified nursing assistant (CNA) on her team express frustration regarding the care for a patient with dementia. The CNA is concerned because the patient has become very uncooperative regarding hygiene and typically resists showering each morning. Which is the highest priority action for the LPN? 1. Remind the CNA to repeat instructions to the patient over and over. 2. Instruct the CNA to continue to use kindness and patience with the patient. 3. Notify the health care provider that the patient's condition is beginning to deteriorate. 4. Encourage the CNA to avoid confrontation and re-attempt bathing the patient later in the day.

4. Encourage the CNA to avoid confrontation and re-attempt bathing the patient later in the day. The LPN should encourage the CNA to avoid confrontation and come back later in the day. Confrontations provoke agitation and may provoke violence. Although patients with dementia may require instructions to be repeated frequently, repetition may not help in this situation. Although the patient with dementia needs the kindness and patience, the CNA should back off when the patient resists morning care. Notifying the health care provider that the patient's condition is beginning to deteriorate is not a realistic intervention for this patient.

Which is the priority goal for a patient with dementia? 1. Prevent pain 2. Reverse mental decline 3. Restrict fluids and electrolytes 4. Maintain the highest level of functioning

4. Maintain the highest level of functioning The goal for patients with dementia is to maintain the highest level of functioning possible as their abilities gradually diminish. Prevention of pain is not the priority. Reversal of mental decline is impossible. Restricting fluids and electrolytes is contraindicated.