neurology

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

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

A 45-year-old patient has a dysfunction of the cerebellum. The nurse will plan interventions to a. prevent falls. b. stabilize mood. c. avoid aspiration. d. improve memory.

ANS: A Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability. DIF: Cognitive Level: Apply (application) REF: 1339-1340 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A 31-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate? a. "MS symptoms may be worse after the pregnancy." b. "Women with MS frequently have premature labor." c. "MS is associated with an increased risk for congenital defects." d. "Symptoms of MS are likely to become worse during pregnancy."

ANS: A During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS. DIF: Cognitive Level: Understand (comprehension) REF: 1429 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects of the medication? a. Inspect the oral mucosa. b. Listen to the lung sounds. c. Auscultate the bowel tones. d. Check pupil reaction to light.

ANS: A Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung sounds, or pupil reaction to light. DIF: Cognitive Level: Apply (application) REF: 1424 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. It will be most important for the nurse to a. assess the patient for a possible head injury. b. give the scheduled dose of divalproex (Depakote). c. document the timing and description of the seizure. d. notify the patient's health care provider about the seizure

ANS: A Rationale: The patient who has had a myoclonic seizure and fall is at risk for head injury and should be evaluated and treated for this possible complication first. Documentation of the seizure, notification of the seizure, and administration of antiseizure medications are also appropriate actions, but the initial action should be assessment for injury.

The nurse assures an anxious family member of a 92-year-old patient who is demonstrating signs of dementia that many causes of dementia are reversible and preventable. What is one example?a.Hypotension b.Alzheimer disease c.Diabetes d.Parkinson disease

ANS: A Some forms of dementia are reversible. Dementia caused by hypotension, anemia, drug toxicity, metabolic disturbance, and malnutrition can all be corrected to abolish the dementia

When caring for a patient who has had a head injury, which assessment information requires the most rapid action by the nurse? a. The patient is more difficult to arouse. b. The patient's pulse is slightly irregular. c. The patient's blood pressure increases from 120/54 to 136/62 mm Hg. d. The patient complains of a headache at pain level 5 of a 10-point scale.

ANS: A The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual

A 27-year-old patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room (select all that apply)? a. Side-rail pads b. Tongue blade c. Oxygen mask d. Suction tubing e. Urinary catheter f. Nasogastric tube

ANS: A, C, D The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Use of tongue blades during a seizure is contraindicated. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. A urinary catheter is not required unless there is urinary retention.

which foods should the person who suffers from migraine headaches avoid? a. alcohol b. caffeine c. milk d chocolate e. marinated foods f. beef

ANS: A,B,D,E

A client with Bell's palsy exhibits facial asymmetry and cannotclose the eye completely on one side. The client is also droolingand has loss of tearing in one eye. The nurse documents that theclient displays symptoms of involvement of which cranial nerves(CNs)? A. CN VI B. CN VII C. CN III D. CN V

ANS: B

Which nursing action has the highest priority for a patient who was admitted 16 hours previously with a C5 spinal cord injury? a. Cardiac monitoring for bradycardia b. Assessment of respiratory rate and effort c. Application of pneumatic compression devices to legs d. Administration of methylprednisolone (Solu-Medrol) infusion

ANS: B Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. Methylprednisolone (Solu-Medrol) is no longer recommended for the treatment of spinal cord injuries. The other actions also are appropriate but are not as important as assessment of respiratory effort.

The nurse assessing a 54-year-old female patient with newly diagnosed trigeminal neuralgia will ask the patient about a. visual problems caused by ptosis. b. triggers leading to facial discomfort. c. poor appetite caused by loss of taste. d. weakness on the affected side of the face.

ANS: B The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.

How would a nurse record the behavior when a patient with Alzheimer disease attempts to eat using a napkin rather than a fork? a.Apraxia b.Agnosia c.Aphasia d.Dysphagia

ANS: B Agnosia is a total or partial loss of the ability to recognize familiar objects or people through sensory stimuli as a result of organic brain damage

An 83-year-old patient has had a stroke. He is right-handed and has a history of hypertension and "little" strokes. He presents with right hemiplegia. To afford him the best visual field, the nurse should approach him a. from the right side. b. from the left side. c. from the center. d. from either side.

ANS: B Another perceptual problem is hemianopia, which is characterized by defective vision or blindness in half of the visual field

Following a thymectomy, a 62-year-old male patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a. Auscultate the patient's bowel sounds. b. Notify the patient's health care provider. c. Administer the prescribed PRN antiemetic drug. d. Give the scheduled dose of prednisone (Deltasone).

ANS: B The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.

A 33-year-old patient with a T4 spinal cord injury asks the nurse whether he will be able to be sexually active. Which initial response by the nurse is best? a. Reflex erections frequently occur, but orgasm may not be possible. b. Sildenafil (Viagra) is used by many patients with spinal cord injury. c. Multiple options are available to maintain sexuality after spinal cord injury. d. Penile injection, prostheses, or vacuum suction devices are possible options.

ANS: C Although sexuality will be changed by the patient's spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patient's individual feelings about sexuality.

The nurse determines that teaching about management of migraine headaches has been effective when the patient says which of the following? a. "I can take the (Topamax) as soon as a headache starts." b. "A glass of wine might help me relax and prevent a headache." c. "I will lie down someplace dark and quiet when the headaches begin." d. "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time."

ANS: C It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate (Topamax) is used to prevent migraines and must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal antiinflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches. DIF: Cognitive Level: Apply (application) REF: 1416 | 1419 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

at the health clinic with a severe migraine headache tells the nurse about having other similar headaches recently. Which initial action should the nurse take? a. Teach about the use of triptan drugs. b. Refer the patient for stress counseling. c. Ask the patient to keep a headache diary. d. Suggest the use of muscle-relaxation techniques.

ANS: C The initial nursing action should be further assessment of the precipitating causes of the headaches, quality, and location of pain, etc. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed first. DIF: Cognitive Level: Apply (application) REF: 1419 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

what is the basic problem that prompts most of the early signs of alzheimer disease? a. changes in mood b. misplacing things c. memory loss that disrupts daily life d. problem with words in speaking

ANS: C memory loss that disrupts daily life

A 76-year-old patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which information is most important for the nurse to report to the health care provider? a. Shuffling gait b. Tremor at rest c. Cogwheel rigidity of limbs d. Uncontrolled head movement

ANS: D Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.

A patient with suspected meningitis is scheduled for a lumbar puncture. Before the procedure, the nurse will plan to a. enforce NPO status for 4 hours. b. transfer the patient to radiology. c. administer a sedative medication. d. help the patient to a lateral position.

ANS: D For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration. DIF: Cognitive Level: Apply (application) REF: 1352 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Which symptom is specific to migraine headaches? a.Tachycardia b.They become worse in the evening c.They involve the entire head d.They are preceded by an aura

ANS: D Migraine headaches are unusual in that signs and symptoms occur before the acute attack

why are the drugs neostigmine prostigmin and pyridostigmine with myasthenia gravis a. imposes speech b. improves visual disturbance c. reduces pain d. promotes nerve impulse transmission

ANS: D Myasthenia gravis is a defect in the transmission of nerve impulses to muscles antibodies block/alter/destroy the receptors for acetylcholine at neuromuscular junction, preventing muscle contraction

A family member of a patient who has just suffered a tonic-clonic seizure is concerned about the patient's deep sleep. What is this behavior called? a.Convalescent period b.Neural recovery period c.Sombulant period d.Postictal period

ANS: D Seizures are followed by a rest period of variable length, called a postictal period

What are the two divisions of the nervous system? a.Somatic and the autonomic b.Cerebellum and the brainstem c.Medulla oblongata and the diencephalon d.Central and the peripheral

ANS: D The central and the peripheral are the two divisions of the nervous system. The autonomic and the somatic are the division of the peripheral nervous system.

A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take? a. Administer IV furosemide (Lasix). b. Initiate high-dose barbiturate therapy. c. Type and crossmatch for blood transfusion. d. Prepare the patient for immediate craniotomy.

ANS: D The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary.

What is the cranial nerve that supplies most of the organs in the thoracic and abdominal cavities and also carries motor fibers to glands that produce digestive juices and other secretions? a. Somatic motor nerve b. Visceral sensory nerve c. Abducens nerve d. Vagus nerve

ANS: D The vagus nerve extends from the throat, larynx, and organs in the thoracic and abdominal cavities. It is responsible for sensations and will accelerate peristalsis when stimulated.

The priority nursing assessment for a 72-year-old patient being admitted with a brainstem infarction is a. reflex reaction time. b. pupil reaction to light. c. level of consciousness. d. respiratory rate and rhythm

ANS: D Vital centers that control respiration are located in the medulla, and these are the priority assessments because changes in respiratory function may be life threatening. The other information will also be collected by the nurse, but it is not as urgent. DIF: Cognitive Level: Apply (application) REF: 1339 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

what does the nurse know about the stroke patient who has expressive aphasia a. has difficulty comprehending spoken and written communication b. cannot make any vocal sounds c. Has total loss and comprehension of language d.can understand the spoken word, but cannot speak

ANS: D can understand the spoken word, but cannot speak

A patient with right-sided weakness that started 1 hour ago is admitted to the emergency department and all these diagnostic tests are ordered. Which order should the nurse act on first? a. Noncontrast computed tomography (CT) scan b. Chest radiograph c. Complete blood count (CBC) d. Electrocardiogram (ECG)

Correct Answer: A Rationale: Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 3 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.

A patient with Parkinson's disease is admitted to the hospital for treatment of an acute infection. Which nursing interventions will be included in the plan of care? (Select all that apply.) a. Cut patient's food into small pieces. b. Provide high protein foods at each meal. c. Observe for sudden exacerbation of symptoms. d. Remind the patient to keep eyes ahead when ambulating. e. Place an arm chair at the patient's bedside. f. Use an elevated toilet seat.

Correct Answer: A, E, F Rationale: Since the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High-protein foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without acute exacerbations. Bradykinesia associated with ambulation is relieved by asking the patient to step over imaginary lines or rice kernels on the floor.

the junction between two communicating neurons is called a

he synapse

A postoperative client has been receiving morphine sulfate every 3 to 4 hours for patient should be sure to implement which measure to reduce risk of adverse effects from medication a. monitor the clients temperature b. encourage fluids c. maintain the client in a supine position d. encourage coughing and deep breathing

ANS : D encourage coughing and deep breathing

The newly admitted patient to the emergency room 30 minutes ago after a fall off a ladder has gradually decreased in consciousness and has slowly reacting pupils, a widening pulse pressure, and verbal responses that are slow and unintelligible. What is the most appropriate position for the patient? a.Neck placed in a neutral position b.Head raised slightly with hips flexed c.Supine in gravity neutral position d.Turn on right side with head elevated

ANS: A Place the neck in a neutral position (not flexed or extended) to promote venous drainage

When admitting an acutely confused 20-year-old patient with a head injury, which action should the nurse take? a. Ask family members about the patient's health history. b. Ask leading questions to assist in obtaining health data. c. Wait until the patient is better oriented to ask questions. d. Obtain only the physiologic neurologic assessment data.

ANS: A When admitting a patient who is likely to be a poor historian, the nurse should obtain health history information from others who have knowledge about the patient's health. Waiting until the patient is oriented or obtaining only physiologic data will result in incomplete assessment data, which could adversely affect decision making about treatment. Asking leading questions may result in inaccurate or incomplete information. DIF: Cognitive Level: Apply (application) REF: 1343 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

An unconscious male patient has just arrived in the emergency department after a head injury caused by a motorcycle crash. Which order should the nurse question? a. Obtain x-rays of the skull and spine. b. Prepare the patient for lumbar puncture. c. Send for computed tomography (CT) scan. d. Perform neurologic checks every 15 minutes.

ANS: B After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure, which could lead to herniation of the brain if a lumbar puncture is performed. The other orders are appropriate. DIF: Cognitive Level: Apply (application) REF: 1349 | 1352 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A client who recently began medication therapy with levodopa (Larodopa) for Parkinson's disease complains of nausea. The nurse reminds the client to do which action to manage this problem? A. Take the medication with three glasses of water B. Eat a snack before taking the Medication. C. Take an antiemetic at the same time as the levodopa D. Lie down and rest after taking the dose

ANS: B Eat a snack before taking the Medication.

As the result of a stroke, a patient has difficulty discerning the position of his body without looking at it. In the nurse's documentation, which would best describe the patient's inability to assess spatial position of his body? a. Agnosia b. Proprioception c. Apraxia d. Sensation

ANS: B Patients may experience a loss of proprioception with a stroke. This may include apraxia and agnosia (a total or partial loss of the ability to recognize familiar objects or people)

Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis? a. Pupil size b. Grip strength c. Respiratory effort d. Level of consciousness

ANS: C Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patient's arms and legs to prevent injury during the seizure. c. Time and observe and record the details of the seizure and postictal state. d. Avoid touching the patient to prevent further nervous system stimulation.

ANS: C Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure. DIF: Cognitive Level: Apply (application) REF: 1422 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which question is likely to elicit the most valid response from the patient who is being interviewed about a neurologic problem? a."Do you have any sensations of pins and needles in your feet?" b."Does the pain radiate from your back into your legs?" c."Can you describe the sensations you are having?" d."Do you ever have any nausea or dizziness?"

ANS: C For patients with suspected neurologic conditions, the presence of many symptoms or subjective data may be significant. Offering leading questions is not beneficial and may allow the patient to give misinformation. Questions should be specific about symptoms.DIF:Cognitive Level: ApplicationREF:Page 677OBJ:8TOP:AssessmentKEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity

Why is the patient with suspected Guillain-Barre Syndrome (GBS) hospitalized immediately? a. The infection needs to be treated with IV antibiotics to prevent paralysis b. The brain may swell quickly causing seizures c. The disease can rapidly progress into respiratory failure d. IV hydration is needed to prevent possible fatal hypotension

ANS: C Hospitalization is necessary for GBS patients because the disease progresses very quickly and respiratory failure may occur.

What is the nurse aware of when assessing a person with a craniocerebral injury? a.Most injuries of this type are irreversible b.Open injuries are always more serious than closed injuries c.Signs and symptoms may not occur until several days after the trauma d.Trauma to the frontal lobe is more significant than to any other area

ANS: C If a patient who has been conscious for several days after head injury loses consciousness or develops neurologic signs and symptoms, a subdural hematoma should be suspected

The nurse is developing a plan of care for a client with a stroke (brain attack) who has right homonymous hemianopsia. Which should the nurse include in the plan of care for the client? a.Place an eye patch on the left eye. b.Place personal articles on the client's right side. c.Approach the client from the right field of vision. d.Instruct the client to turn the head to scan the right visual field

ANS: D Homonymous hemianopsia is a loss of half of the visual field. The nurse instructs the client to scan the environment and stands within the client's intact field of vision. The nurse should not patch the eye because the client does not have double vision. The client should have objects placed in the intact fields of vision, and the nurse should approach the client from the intact side. * Focus on the subject, a visual problem, and recall the definition of homonymous hemianopsia. Recalling that the client loses half of the visual field will assist in directing you to the correct option.

When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? a. The patient has a positive Kernig's sign. b. The patient complains of having a stiff neck. c. The patient's temperature is 101° F (38.3° C). d. The patient's blood pressure is 86/42 mm Hg

ANS: D Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension. DIF: Cognitive Level: Application REF: 1452-1453

A client is suspected of having myasthenia gravis. Edrophonium (Tensilon) 2 mg IV administered to determine the diagnosis. Which of the following indicates that the client has myasthenia gravis? a) an increase in muscle strength within 1 to 3 minutes following administration of the medication b) a decrease in muscle strength within 1 to 3 minutes following administration of the medication c) joint pain swelling following administration of the medication next 15 mins d) feelings of faintness, dizziness, hypotension, and signs of flushing in the client

ANS:A an increase in muscle strength within 1 to 3 minutes following administration of the medication

The client with myasthenia gravis becomes increasingly weaker. The physician injects a dose of edrophonium (Tensilon) to determine whether the client is experiencing a myasthenic crisis or a cholinergic crisis. The nurse expects that the client will have which of the following reactions if the client is in cholinergic crisis? A. No change in the condition B. Complaints of muscle spasms C. An improvement of the weakness D. A temporary worsening of the condition

ANS:D Rationale: An edrophonium (Tensilon) injection makes the client in cholinergic crisis temporarily worse. An improvement of the condition ("an improvement of the weakness") indicates myasthenic crisis. The other two options are unrelated to the test.

1. The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address? a. The patient smokes a pack of cigarettes daily. b. The patient's blood pressure (BP) is chronically between 150/80 to 180/90 mm Hg. c. The patient works at a desk and relaxes by watching television. d. The patient is 25 pounds above the ideal weight.

Correct Answer: B Rationale: Hypertension is the most important modifiable risk factor. Smoking, physical inactivity, and obesity all contribute to stroke risk but not so much as hypertension.

A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Obtain the Glasgow Coma Scale score. b. Check the respiratory rate. c. Monitor the blood pressure. d. Send the patient for a CT scan.

Correct Answer: B Rationale: The initial nursing action should be to assess the airway and take any needed actions to assure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, circulation) are completed.

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

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

A 72-year-old patient hospitalized with pneumonia is disoriented and confused 2 days after admission. Which assessment information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia? a. The patient is disoriented to place and time but oriented to person. b. The patient has a history of increasing confusion over several years. c. The patient's speech is fragmented and incoherent. d. The patient was oriented and alert when admitted.

Correct Answer: D Rationale: 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. Cognitive Level: Application Text Reference: p. 1562 Nursing Process: Assessment NCLEX: Physiological Integrity