Chapter 23: Neurocognitive Disorders
A patient's family member brings in a list of medications the patient is taking for Alzheimer disease. The patient has begun experiencing psychotic symptoms as well as dementia. Medication from which class will likely be discontinued? 1. Antipsychotics 2. Anticonvulsants 3. Antidepressants 4. Antianxiety agents
1. Antipsychotics When administered to patients with dementia, antipsychotics can cause psychotic side effects. Antidepressants, antianxiety agents, and anticonvulsants can be used in various combinations without causing psychotic symptoms.
Which question should be asked when considering the evaluation of outcomes for a patient experiencing cognitive dysfunction? Select all that apply. 1. Are the stated outcomes measureable? 2. Are the patient's cognitive skills deteriorating? 3. Is the patient capable of achieving the outcomes? 4. Are the caregivers capable of creating outcomes? 5. When were the patient's outcomes last evaluated?
1. Are the stated outcomes measureable? 2. Are the patient's cognitive skills deteriorating? 3. Is the patient capable of achieving the outcomes? 5. When were the patient's outcomes last evaluated?
Which practice demonstrates a proactive approach to minimizing the stress commonly experienced by nursing staff caring for the cognitively impaired patient? Select all that apply. 1. Realistic patient outcomes 2. Mandatory transfers off of units 3. Small nurse-to-patient care ratios 4. Thorough understanding of the disorder 5. Reasonable expectations of patient abilities
1. Realistic patient outcomes 4. Thorough understanding of the disorder 5. Reasonable expectations of patient abilities Because stress is a common occurrence when working with persons with cognitive impairments, nurses need to be proactive in minimizing its effects, which can be facilitated by having an understanding of the disease and realistic expectations. Small nurse-to-patient care ratios and mandatory transfers off of units are not realistic and are unnecessary when staff is informed and well supported in their caregiving.
A 75-year-old patient is hospitalized with sudden onset confusion and disorientation. The patient wanders and becomes agitated without any apparent stimulus. What is the highest priority nursing diagnosis? 1. Risk for injury 2. Acute confusion 3. Impaired memory 4. Self-care deficit, bathing, or hygiene
1. Risk for injury Risk for injury; acute confusion; impaired memory; and self-care deficit, bathing, or hygiene are diagnoses likely to apply in this situation; however, safety is the nurse's highest priority.
A patient diagnosed with delirium strikes out physically at a staff member. What is the most likely cause of this behavior? 1. State of fear 2. Physical illness 3. An unmet physical need 4. The need for social interaction
1. State of fear Patients with delirium often misinterpret reality, perceiving threat where none actually exists. Delirious patients who are fearful may strike out at others, seemingly without provocation. Physical illness, an unmet physical need, or the need for social interaction generally are not associated with such aggressive behavior.
Which medication is aimed at preventing the breakdown of acetylcholine? Select all that apply. 1. Tacrine 2. Donepezil 3. Rivastigmine 4. Memantine 5. Galantamine
1. Tacrine 2. Donepezil 3. Rivastigmine 5. Galantamine Because a deficiency of acetylcholine has been linked to Alzheimer's disease, medications aimed at preventing its breakdown (cholinesterase inhibitors) have been developed, including tacrine hydrochloride, donepezil, rivastigmine, and galantamine. Memantine normalizes levels of glutamate, a neurotransmitter that may contribute to neurodegeneration.
Which behavior is associated with typical age-related cognitive changes? Select all that apply. 1. Taking 30 minutes to find one's misplaced car keys. 2. Having the electricity turned off for lack of payment. 3. Experiencing difficulty recalling a synonym for happy. 4. Forgetting the address of the first apartment you rented. 5. Failing to pay the credit card bill while away on vacation.
1. Taking 30 minutes to find one's misplaced car keys. 3. Experiencing difficulty recalling a synonym for happy. 4. Forgetting the address of the first apartment you rented. 5. Failing to pay the credit card bill while away on vacation. Typical age-related cognitive changes include occasional examples of memory lapse, poor judgment, and omissions. The more serious, atypical changes involve complete, constant, or chronic issues with memory and cognition.
A nurse was assigned to select patients with Alzheimer's disease for a clinical trial of a new drug from a geriatric population. Based on what appropriate symptoms does the nurse select the patients? Select all that apply. 1. The patient has difficulty in conversing with others. 2. The patient has poor judgment and decision-making. 3. The patient reports forgetting to pay the electric bills. 4. The patient reports frequently losing things and tracing them later. 5. The patient sometimes forgets which word to use during a conversation.
1. The patient has difficulty in conversing with others. 2. The patient has poor judgment and decision-making. Geriatric patients normally have minor age-related deflects in memory. The nurse should be able to differentiate between the normal age-related changes and signs of Alzheimer's disease. Patients with Alzheimer's disease have difficulty in conversation and poor judgment and decision making. Other symptoms include inability to manage a budget, losing track of the date or the season, misplacing things and being unable to trace them. Normal age-related changes include forgetting which word to use and losing things frequently. Missing monthly payments and making a bad decision once in a while is a normal behavior and does not indicate Alzheimer's disease.
A patient with Parkinson's disease reports that bugs are crawling on his bed. The nurse checks the bed and finds peanuts on the bed. What does the nurse conclude from the patient's behavior? 1. The patient has impaired environmental interpretation syndrome. 2. The patient has delusions. 3. The patient has developed an allergy to peanuts. 4. The patient has a skin disorder.
1. The patient has impaired environmental interpretation syndrome. Patients with Parkinson's disease have confusion and dementia, and have impaired environmental interpretation syndrome. It is characterized by hallucinations and illusions. The patients tend to mistake benign objects for objects which are sinister and frightening. The patients may have tactile hallucinations, but not suffer from delusions. An allergy to peanuts or developing a skin disorder are unlikely causes of the patient's complaint, as these disorders are accompanied by other symptoms as well.
A Chinese-American patient has been diagnosed with dementia. What should the nurse keep in mind when addressing the needs of the family caregivers? Select all that apply. 1. They do not seek help from others. 2. They believe dementia is due to fate. 3. They associate dementia with stigma. 4. They perceive caregiving as burdensome. 5. They feel obligated to sacrifice individual needs. 6. They believe memory loss in early dementia is not a mental disease.
1. They do not seek help from others. 2. They believe dementia is due to fate. 3. They associate dementia with stigma. 5. They feel obligated to sacrifice individual needs. 6. They believe memory loss in early dementia is not a mental disease. Chinese-Americans depict dementia as fate or wrongdoing rather than a disease. They are less likely to seek help from others. Filial piety and family harmony are important, which emphasizes honor and devotion to parents. They feel obligated to sacrifice individual needs and wants. As the disease progresses, dementia is viewed as a mental illness with associated stigma and resulting in feelings of humiliation. Chinese-Americans do not perceive their caregiving role as burdensome. They believe that memory loss in early dementia is a part of the normal aging process. It is not viewed as a mental illness.
A female patient is brought to the hospital by her daughter, who visited the patient this morning and found her to be confused and disoriented. When the patient is admitted, the daughter states, "I'll take her glasses and hearing aid home, so they don't get lost." What would be the best response from the nurse? 1. "That will be fine. I'll have you sign our hospital release form." 2. "I would like to have your mother wear them. It will help her to be less confused." 3. "Don't worry. You can leave them at her bedside. We are insured for losses of this sort." 4. "Because we do not have a copy of durable power of attorney, we cannot release them to you."
2. "I would like to have your mother wear them. It will help her to be less confused." Patients with cognitive disorders usually profit from being able to see and hear clearly. Confusion is reduced through the use of glasses and hearing aids.
A patient diagnosed with Alzheimer's disease picks up his or her glasses from the bedside table but does not recognize what they are or their purpose. The nurse will document this behavior using which term? 1. Apraxia 2. Agnosia 3 Aphasia 4 Agraphia
2. Agnosia Agnosia is the loss of the sensory ability to recognize objects. Apraxia is the loss of purposeful movement in the absence of motor or sensory impairment. Aphasia is the loss of language ability. Agraphia is the loss of the ability to read or write.
Which nursing intervention would be most appropriate for an older individual suspected of being at risk for the development of the unique symptoms of delirium? 1. Assuring that the individual is ambulated sufficiently. 2. Assessing orientation to person, place, and time every two hours. 3. Cutting the individual's food into small pieces to avoid the risk of choking. 4. Assuring that the individual is dressed warmly to avoid the risk of hypothermia.
2. Assessing orientation to person, place, and time every two hours. Delirium reduces awareness of the environment that involves sensory misperceptions and disordered thought (disturbed attention, memory, thinking, and orientation) and also disturbances of psychomotor activity and the sleep-wake cycle. These disturbances develop rapidly (over hours to days). Frequent assessment of an individual at risk for developing delirium for orientation would be most appropriate. Assuring ambulation, cutting food into small pieces, and assuring warm clothing are appropriate but not needs unique to an individual at risk for developing delirium.
The family caregivers of an elderly Alzheimer's disease patient are feeling overburdened and overwhelmed by the situation and wish to admit the patient to an assisted care facility. What could be the primary reason? 1. Family discord 2.Caregiver role strain 3 Disruption of social life 4 Distress, guilt, rejection
2. Caregiver role strain Many families take care of the patient with Alzheimer's disease until death. Others, however, find that they can no longer cope with aggressive behavior, incontinence, wandering, unsafe behaviors, or disruptive nocturnal activity. This is known as caregiver role strain. In such cases, the caregivers may admit the patient to an assisted care facility. Disruption of social life, distress, guilt, rejection, and family discord can all be burdens on the family but are not the primary reasons in this case.
An elderly patient is diagnosed with Alzheimer's disease. What characteristic features may be seen in this patient? Select all that apply. 1.Speaks rapidly, inappropriately, and incoherently 2. Forgets familiar words or the location of everyday objects 3 . Becomes moody or withdrawn, especially in challenging situations 4. Shows altered awareness and is unable to focus, or sustain attention 5. Has increasing and frequent trouble controlling bladder and bowels
2. Forgets familiar words or the location of everyday objects 3. Becomes moody or withdrawn, especially in challenging situations 5. Has increasing and frequent trouble controlling bladder and bowels Alzheimer's disease is characterized by progressive deterioration of cognitive functioning, including forgetting familiar words or the location of everyday objects. The patient becomes moody or withdrawn, especially in socially or mentally challenging situations. The patient also has increasing and frequent trouble controlling their bladder and bowels. Delirium is an acute cognitive disturbance where the patient's speech is rapid, inappropriate, incoherent, and rambling. There is an alteration in consciousness levels. This manifests as altered awareness and inability to focus, sustain, and shift attention.
A patient's family expresses concern that the patient is developing Alzheimer disease. The patient is now 65 and was once a professional wrestler. How might this history affect the diagnosis? 1. This history will not affect the diagnosis. 2. History of head trauma is a risk factor for dementia. 3. The patient is too young to have Alzheimer disease. 4. As an athlete, the patient is less likely to have Alzheimer disease.
2. History of head trauma is a risk factor for dementia. If the patient was a professional athlete in a contact sport, there may be a history of head injury, which will affect the diagnosis. The patient's history can indeed affect the diagnosis. Although most patients who are diagnosed with Alzheimer disease are 75 or older, it is not impossible for younger patients to show signs of the disease. Other than the risk of head trauma, athletes are no more or less likely to develop the disease.
Which is a drawback of early cholinesterase inhibitors? 1. Constipation 2. Liver toxicity 3. Only useful in mild dementia 4. Increased acetylcholine levels
2. Liver toxicity Earlier forms of cholinesterase inhibitors, such as tacrine, caused liver toxicity, causing them to be withdrawn from the US market in 2012. Increasing availability of acetylcholine is a benefit for patients with dementia. These drugs are not beneficial for people with mild dementia. The side effects include nausea, vomiting, and diarrhea, not constipation.
An elderly patient, who had been healthy and living independently, was hospitalized with heart failure. The patient was treated with diuretics and antihypertensive medications. On the third hospital day, the patient became very irritable and said, "Little yellow bugs are crawling across my sheets." What is the best analysis of this scenario? 1. the pt has delusions secondary to depression 2. the pt is experiencing illusions secondary to delirium 3. Early dementia emerged because of the stress of the physical illness 4. doses of antihypertensive drugs have not managed the patients BP
2. The patient is experiencing illusions secondary to delirium Delirium is the most common complication of hospitalizations in the older adults. Illusions (errors in perception of sensory stimuli) indicate this patient is confused. Illusions, irritability, and restlessness are common in delirium. The scenario doesn't suggest the pt has dementia or depression. The pt is likely experiencing toxicity associated with the multiple medications, which is a common cause of delirium.
An elderly patient is hospitalized with pneumonia and treated with multiple antibiotics. After two days, the patient becomes irritable and restless, and says to the nurse, "My pet parakeet flew across the room." A family member says the patient has been healthy and living independently but does not own a pet. What is the most likely analysis of this scenario? 1. The patient is delusional and likely experiencing depression. 2. The patient is experiencing illusions secondary to delirium. 3. The antibiotic doses have been inadequate to treat the infection. 4. Dementia has emerged as the result of the stress of the physical illness.
2. The patient is experiencing illusions secondary to delirium. The onset of the change in mental status is acute, which is characteristic of delirium. The vision of a bird flying in the room is likely an illusion, another common characteristic of delirium. The patient's condition could be the result of the medical illness, toxicity of the drug regimen, overstimulation from the hospital environment, alcohol withdrawal, or other reasons.
A patient with cognitive impairment is diagnosed with aphasia. Which symptom is the nurse most likely to find in the patient? 1. The patient wears socks on the hands. 2. The patient talks rapidly and foolishly. 3. The patient doesn't answer the nurse. 4. The patient doesn't identify sounds.
2. The patient talks rapidly and foolishly. Patients with impaired cognition show symptoms like aphasia, apraxia, preservation, and agnosia. The patient with aphasia has reduced language ability, seen as inability to use the correct word and talking rapidly and foolishly. Loss of purposeful movement is called apraxia. The person is unable to put on clothes and may wear socks on hands. The patient with preservation avoids answering the question to maintain self-esteem. Inability to identify sounds, objects, and people is known as agnosia.
A nurse communicates with a diabetic patient during their regular check-up. The nurse finds that the patient is showing symptoms of Alzheimer's disease. Which response by the patient supports the nurse's diagnosis? 1. "I missed my walk last week." 2. "I regularly go for a walk, you can ask my daughter." 3. "I regularly meet Mr. Abraham Lincoln during my walk." 4. "I don't go for a walk, because it is very cold in the morning."
3. "I regularly meet Mr. Abraham Lincoln during my walk." Patients with Alzheimer's have progressive deterioration of memory. They forget to take medication and perform important self-care activities. They tend to hide the truth by creating stories like they go for a walk with Abraham Lincoln. This behavior is called confabulation. It is not the same as lying because patients do it unconsciously to maintain self-esteem. The statement that the patient is going for a regular walk which can be confirmed with the daughter indicates confidence. The statement that the patient missed the walk indicates that the patient remembers the period and also accepts the mistake. The statement that the patient doesn't go for a walk because of cold weather indicates that the patient accepts the mistake without any guilt.
A patient is brought to the emergency room after falling in the street a mile from home. There are no serious injuries. The patient's medical record states the patient has Alzheimer disease, and the patient asks the nurse call his or her spouse, who is long deceased. What should be the focus of care? 1. Family therapy for the patient's family members 2. Health promotion, instructing the patient on ways to be safe 3. Evaluation of the home situation for safety and level of care 4. Biological reasons for the ER visit and possible psychiatric care
3. Evaluation of the home situation for safety and level of care Because patients with Alzheimer disease are at risk for wandering and getting lost, this patient's living situation should be assessed for security; he or she may require full-time care. Because the patient has no serious injuries, biological needs have already been addressed. Telling the patient how to be safe will not be effective due to the nature of the disorder. Family therapy may be helpful, but this is not the priority goal.
The nurse is assessing a patient suspected of Alzheimer's disease (AD). What action by the patient does the nurse identify as a sign of agnosia? 1. Babbles and speaks incoherently when asked any question 2. Has problem in recalling what was served for breakfast an hour ago 3. Has problem in identifying familiar sounds like the ring of the telephone 4. Talks about how he or she convinced the President to pass a particular law
3. Has problem in identifying familiar sounds like the ring of the telephone When the patient is unable to identify the ring of the telephone, it means there is a loss of sensory ability to recognize familiar sounds. The nurse recognizes it as a feature of auditory agnosia. If the patient babbles and speaks incoherently, it means there is a loss of language ability. The nurse identifies this as a sign of aphasia. In AD, there is a gradual deterioration of recent and remote memory. If the patient is unable to recall what was served for breakfast an hour ago, it indicates impairment of recent memory. Patients with AD often confabulate in an unconscious attempt to maintain self-esteem. When the patient talks about how the President's decision was influenced by the patient, the nurse should recognize it as confabulation.
Which risk factor for delirium is a direct result of external factors? 1. Fractures 2. Older age 3. Polypharmacy 4. Multiple comorbidities
3. Polypharmacy Delirium may occur as a result of polypharmacy, which can occur from a lack of continuity of care and communication, external factors. Older age and multiple conditions are internal factors. Fractures may be a result of an external cause but could also be a result of internal osteoporotic changes.
Every evening, several residents on the Alzheimer disease wing of a long-term care facility become excessively agitated. What is the term for this phenomenon? 1. Apraxia 2. Agraphia 3. Sundowning 4. Confabulation
3. Sundowning Sundowning is the term for the increase in agitation and decrease in mood in the later part of the day or night common among patients with Alzheimer disease. Confabulation describes the creation of vivid stories instead of actual memories. Agraphia refers to diminishment of reading and writing abilities. Apraxia is the loss of purposeful movement.
The term "perceptual disturbance" refers to difficulty accomplishing what task? 1. Formulating words appropriately. 2. Performing purposeful motor movements. 3. Changing one's way of thinking to accommodate new information. 4. The processing of information about one's internal and external environment.
4. The processing of information about one's internal and external environment. Perceptual disturbance refers to an impaired ability to process intellectual, sensory, and emotional data in a logical, meaningful way. Changing one's way of thinking to accommodate new information, performing purposeful motor movements, and formulating words appropriately fail to adequately describe the term perceptual disturbance.
