dementia delirium questions

A nurse is assessing a client diagnosed with Alzheimer's disease. As part of the assessment, the nurse asks the client to identify common objects. The nurse is assessing for what?

Agnosia

What is the primary sign of delirium?

An altered level of consciousness

A client has vascular neurocognitive disorder. When teaching the family about the cause of this disorder, which would the nurse expect to integrate into the explanation?

Blood flow in the vessels to the brain are blocked.

Changes that are found during the mental status examination of a client diagnosed with delirium include what?

Difficulty focusing

Which is the hallmark of beginning mild dementia?

Forgetfulness

A client with amnestic disorder is being evaluated for dementia. Which is a diagnostic characteristic of amnestic disorder?

History and physical examination indicative of memory impairment

The client is an 84-year-old suffering from delirium. The client has been in a nursing home for the past 2 years but recently is becoming combative and has become a threat to staff. Which medication would the client most likely receive for these symptoms?

Haloperidol

Which is a metabolic cause of delirium?

Hypoglycemia

A older adult client develops delirium secondary to an infection. Which would be the most likely cause?

Pneumonia

Which nursing diagnosis would be the priority for the client experiencing acute delirium?

Risk for injury related to confusion and cognitive deficits

The geriatrician has prescribed an 80-year-old client donepezil in order to treat the client's dementia, Alzheimer's type. Which teaching points should the nurse provide to the client's spouse about the new medication?

"Donepezil won't cure your spouse's dementia of Alzheimer's type, but it has the potential to slow down the progression of the disease."

A 73-year-old client has been brought to the emergency department by the client's adult children due to abrupt and uncharacteristic changes in behavior, including impairments of memory and judgment. The subsequent history and diagnostic testing have resulted in a diagnosis of delirium. Which teaching point about the client's diagnosis should the nurse provide to the family?

"If the underlying cause of delirium is identified and treated, most people return to their previous level of functioning."

The nurse is assessing a client who has received a tentative diagnosis of delirium. The nurse is explaining to the family about the major cause of the client's condition. Which statement by the nurse would be most appropriate?

"The client's diagnosis is primarily based on the rapid onset of the change in consciousness."

An 80-year-old client with Alzheimer's disease is prescribed donepezil. Which teaching points should the nurse provide to the client's spouse about the new medication?

"The drug won't cure the client's Alzheimer's, but it has the potential to slow down the progression of the disease."

A client diagnosed with Alzheimer's disease says, "I'm so afraid. Where am I? Where is my family?" How should the nurse respond?

"You are in the hospital and you're safe here. Your family will return at 10 o'clock, which is 1 hour from now."

The nurse understands that numerous comorbidities can contribute to the development of dementia. Which client may be at risk for dementia?

A 49-year-old client whose human immunodeficiency virus (HIV) has progressed to acquired immunodeficiency syndrome (AIDS)

Parkinson's disease is thought to be caused by which neural change?

A loss of neurons at the basal ganglia

A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patient's speech is fragmented and incoherent. c. The patient is oriented to person but disoriented to place and time. d. The patient has a history of increasing confusion over several years.

ANS: A-The patient was oriented and alert when admitted 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.

Which action will help the nurse determine whether a new patient's confusion is caused by dementia or delirium? a. Administer the Mini-Mental Status Exam. b. Use the Confusion Assessment Method tool. c. Determine whether there is a family history of dementia. d. Obtain a list of the medications that the patient usually takes.

ANS: B The Confusion Assessment Method tool has been extensively tested in assessing delirium.

A patient who has severe Alzheimer's disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care? a. Encourage the patient to discuss events from the past. b. Maintain a consistent daily routine for the patient's care. c. Reorient the patient to the date and time every 2 to 3 hours. d. Provide the patient with current newspapers and magazines.

ANS: B Providing a consistent routine will decrease anxiety and confusion for the patient.

A client was admitted to an inpatient unit with a diagnosis of dementia. A nursing assessment and interview of the client would include what?

Intellectual ability, health history, and self-care ability

The nurse is administering a mental status examination to a 48-year-old patient who has hypertension. The nurse suspects depression when the patient responds to the nurse's questions with a. "Is that right?" b. "I don't know." c. "Wait, let me think about that." d. "Who are those people over there?"

ANS: B-"I don't know." Answers such as "I don't know" are more typical of depression than dementia. The response "Who are those people over there?" is more typical of the distraction seen in a patient with delirium. The remaining two answers are more typical of a patient with mild to moderate dementia.

Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia? a. Setting the medications up monthly in a medication box b. Having the patient's family member administer the medication c. Posting reminders to take the medications in the patient's house d. Calling the patient weekly with a reminder to take the medication

ANS: B-Having the patient's family member administer the medication Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the drug.

Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had an appendectomy 2 days ago? a. Provide complete personal hygiene care for the patient. b. Remind the patient frequently about being in the hospital. c. Reposition the patient frequently to avoid skin breakdown. d. Place suction at the bedside to decrease the risk for aspiration.

ANS: B-Remind the patient frequently about being in the hospital. The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.

A 56-year-old patient in the outpatient clinic is diagnosed with mild cognitive impairment (MCI).Which action will the nurse include in the plan of care? a. Suggest a move into an assisted living facility. b. Schedule the patient for more frequent appointments. c. Ask family members to supervise the patient's daily activities. d. Discuss the preventive use of acetylcholinesterase medications.

ANS: B-Schedule the patient for more frequent appointments

A 68-year-old patient is diagnosed with moderate dementia after multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. difficulty eating and swallowing. c. loss of recent and long-term memory. d. fluctuating ability to perform simple tasks.

ANS: C Loss of both recent and long-term memory is characteristic of moderate dementia

A patient is being evaluated for Alzheimer's disease (AD). The nurse explains to the patient's adult children that a. the most important risk factor for AD is a family history of the disorder. b. new drugs have been shown to reverse AD dramatically in some patients. c. a diagnosis of AD is made only after other causes of dementia are ruled out. d. the presence of brain atrophy detected by magnetic resonance imaging (MRI) will confirm the diagnosis of AD.

ANS: C The diagnosis of AD is usually one of exclusion. Age is the most important risk factor for development of AD

A 71-year-old patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care? a. Reorient the patient several times daily. b. Have the family bring in familiar items. c. Place the patient in a room close to the nurses' station. d. Ask the patient why the wandering episodes have occurred.

ANS: C-Place the patient in a room close to the nurses' station. Patients at risk for problems with safety require close supervision. Placing the patient near the nurse's station will allow nursing staff to observe the patient more closely

When administering a mental status examination to a patient with delirium, the nurse should a. wait until the patient is well-rested. b. administer an anxiolytic medication. c. choose a place without distracting stimuli. d. reorient the patient during the examination.

ANS: C-choose a place without distracting stimuli. Because overstimulation by environmental factors can distract the patient from the task of answering the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient's delirium.

A 72-year-old female patient is brought to the clinic by the patient's spouse, who reports that she is unable to solve common problems around the house. To obtain information about the patient's current mental status, which question should the nurse ask the patient? a. "Are you sad?" b. "How is your self-image?" c. "Where were you were born?" d. "What did you eat for breakfast?"

ANS: D-"What did you eat for breakfast?" This question tests the patient's short-term memory, which is decreased in the mild stage of Alzheimer's disease or dementia

The nurse is concerned about a postoperative patient's risk for injury during an episode of delirium. The most appropriate action by the nurse is to a. secure the patient in bed using a soft chest restraint. b. ask the health care provider to order an antipsychotic drug. c. instruct family members to remain with the patient and prevent injury. d. assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation.

ANS: D-assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation.

A client is diagnosed with Alzheimer's disease. While assessing the client, the nurse notes that the client has trouble identifying objects such as a key and spoon. The nurse would document this as what?

Agnosia

When assessing a client with dementia, the nurse notes that the client is having difficulty identifying common items, such as a ball or book. The nurse interprets this finding as what?

Agnosia

The nurse is caring for a client with dementia. The client's brain images show atrophy of cerebral neurons and enlargement of the third and fourth ventricles. What is the cause of dementia in this client?

Alzheimer's disease

A client diagnosed with Alzheimer's disease has an alteration in language ability. This alteration would be documented as what?

Aphasia

A client with dementia is having difficulty finding the words that the client wants to use. When the client could not remember the name of the client's shoes, he referred to them as, "the things you put on your feet." What is the name for this condition?

Aphasia

Which term is used to describe the inability to execute motor functioning, despite intact motor abilities?

Apraxia

When conducting a nursing assessment of a client experiencing moderate cognitive dysfunction, the nurse can best prepare for an effective interview by ensuring what?

Asking a family member to be present during the assessment

After teaching a group of nursing students about drugs used to treat Alzheimer's disease, the instructor determines that additional teaching is needed when the group identifies which as a N-methyl-D-aspartic acid (NMDA) receptor antagonist?

Memantine

When administering a mental status examination to a patient, the nurse suspects depression when the patient responds with a. "I don't know." b. "Is that the right answer?" c. "Wait, let me think about that." d. "Who are those people over there?"

Correct Answer: A Rationale: Answers such as "I don't know" are more typical of depression. The response "Who are those people over there?" is more typical of the distraction seen in a patient with delirium. The remaining two answers are more typical of a patient with dementia.

The nurse has identified the nursing diagnosis of disturbed thought processes related to effects of dementia for a patient with late-stage Alzheimer's disease (AD). An appropriate intervention for this problem is to a. maintain a consistent daily routine for the patient's care. b. encourage the patient to discuss events from the past. c. reorient the patient to the date and time every few hours. d. provide the patient with current newspapers and magazines.

Correct Answer: A Rationale: Providing a consistent routine will decrease anxiety and confusion for the patient. In late-stage AD, the patient will not remember events from the past. Reorientation to time and place will not be helpful to the patient with late-stage AD. The patient with late-stage AD will not be able to read. Cognitive Level: Application Text Reference: p. 1571 Nursing Process: Planning NCLEX: Physiological Integrity

Risperidone (Risperdal) is prescribed for an outpatient with moderate Alzheimer's disease (AD). Which information obtained by the nurse at the next clinic appointment indicates that the medication is effective? a. The patient has less agitation. b. The patient is dressed appropriately. c. The patient is able to swallow a pill. d. The patient's speech is clearer.

Correct Answer: A Rationale: Risperidone is an antipsychotic used to treat the agitation, aggression, and behavioral problems associated with AD. The other improvements might occur with cholinesterase inhibitors. Cognitive Level: Application Text Reference: p. 1568 Nursing Process: Evaluation NCLEX: Physiological Integrity

When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse include? a. Reminding the patient frequently about being in the hospital b. Placing suction at the bedside to decrease the risk for aspiration c. Providing complete personal hygiene care for the patient d. Repositioning the patient frequently to avoid skin breakdown

Correct Answer: A Rationale: The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility. Cognitive Level: Application Text Reference: p. 1563 Nursing Process: Planning NCLEX: Physiological Integrity

A family member of a patient with possible Alzheimer's disease asks the nurse the purpose of the Mini-Mental State Examination (MMSE). Which response by the nurse is appropriate? a. The MMSE helps in establishing the diagnosis of Alzheimer's disease (AD). b. The MMSE is useful in determining the degree of mental impairment. c. The MMSE determines the choice of the most appropriate treatment. d. The MMSE aids in differentiating acute delirium from chronic dementia.

Correct Answer: B Rationale: The MMSE establishes the degree of mental impairment at the time it is given. It does not establish a diagnosis of AD but when given repeatedly over time may help to determine the progression of AD. The choice of treatment is made on the basis of multiple data, not just the MMSE. The MMSE may be abnormal with either delirium or dementia and is not useful in determining which condition the patient has. Cognitive Level: Application Text Reference: p. 1563 Nursing Process: Implementation NCLEX: Physiological Integrity

When teaching the spouse of a patient who is being evaluated for Alzheimer's disease (AD) about the disorder, the nurse explains that a. the most important risk factor for AD is a family history of the disorder. b. a diagnosis of AD can be made only when other causes of dementia have been ruled out. c. new drugs have been shown to reverse AD dramatically in some patients. d. the presence of brain atrophy detected by MRI confirms the diagnosis of AD in patients with dementia.

Correct Answer: B Rationale: The diagnosis of AD is one of exclusion. Age is the most important risk factor for development of AD. Drugs can slow the deterioration but do not dramatically reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in other diseases as well. Cognitive Level: Comprehension Text Reference: p. 1568 Nursing Process: Implementation NCLEX: Physiological Integrity

During the morning change-of-shift report at the long-term care facility, the nurse learns that the patient with dementia has had sundowning. Which nursing action should the nurse take while caring for the patient? a. Move the patient to a quieter room at night. b. Open the blinds in the patient's room and provide frequent activities. c. Have the patient take a brief mid-morning nap. d. Provide hourly orientation to time of day.

Correct Answer: B Rationale: The most likely cause of sundowning is a disruption in circadian rhythms and keeping the patient active and in daylight will help to reestablish a more normal circadian pattern. Moving the patient to a different room might increase confusion. Taking a nap will interfere with nighttime sleep. Hourly orientation will not be helpful in a patient with memory difficulties. Cognitive Level: Application Text Reference: p. 1573 Nursing Process: Implementation NCLEX: Safe and Effective Care Environment

To protect a patient from injury during an episode of delirium, the most appropriate action by the nurse is to a. have a close family member remain with the patient and provide reassurance. b. assign a staff member to stay with the patient and offer frequent reorientation. c. ask the health care provider about ordering an antipsychotic drug. d. secure the patient in bed with a soft chest restraint.

Correct Answer: B Rationale: The priority goal is to protect the patient from harm, and a staff member will be most experienced in providing safe care. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have multiple side effects. Restraints are sometimes used but tend to increase agitation and disorientation. Cognitive Level: Application Text Reference: p. 1577 Nursing Process: Implementation NCLEX: Physiological Integrity

3. When administering a mental status examination to a patient with delirium, the nurse should a. give the examination when the patient is well-rested. b. reorient the patient as needed during the examination. c. choose a place without distracting environmental stimuli. d. medicate the patient first to reduce anxiety.

Correct Answer: C Rationale: Because overstimulation by environmental factors can distract the patient from the task of answering the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient's delirium. Cognitive Level: Application Text Reference: pp. 1562, 1576-1577 Nursing Process: Implementation NCLEX: Physiological Integrity

A home-health patient with Alzheimer's disease (AD) and mild dementia has a new prescription for donepezil (Aricept). Which nursing action will be most effective in ensuring compliance with the medication? a. Setting the medications up weekly in a medication box b. Calling the patient daily with a reminder to take the medication c. Having the patient's spouse administer the medication d. Posting reminders to take the medications in the patient's house

Correct Answer: C Rationale: Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the Aricept. The other nursing actions will not be as effective in ensuring that the patient takes the medications. Cognitive Level: Application Text Reference: pp. 1563, 1567 Nursing Process: Implementation NCLEX: Physiological Integrity

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. Cognitive Level: Application Text Reference: p. 1573 Nursing Process: Implementation NCLEX: Physiological Integrity

Coexisting dementia and depression are identified in a patient with Parkinson's disease. The nurse anticipates that the greatest improvement in the patient's condition will occur with administration of a. antipsychotic drugs. b. anticholinergic agents. c. dopaminergic agents and antidepressant drugs. d. selective serotonin reuptake inhibitor (SSRI) agents.

Correct Answer: C Rationale: Parkinson's disease and depression are both potentially reversible conditions, and the patient's symptoms that are caused by these two conditions will improve with appropriate treatment. Anticholinergic agents are likely to worsen the patient's condition because they will block the effect of acetylcholine at the synaptic cleft. There is no indication that the patient needs an antipsychotic agent at this time. A selective serotonin reuptake inhibitor (SSRI) may be effective for the depression, but it does not address the patient's other conditions. Cognitive Level: Application Text Reference: p. 1563 Nursing Process: Planning NCLEX: Physiological Integrity

When assessing a patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility, the nurse learns that the patient has had several episodes of wandering away from home. Which nursing action will the nurse include in the plan of care? a. Ask the patient why the wandering episodes have occurred. b. Reorient the patient to the new living situation several times daily. c. Place the patient in a room close to the nurses' station. d. Have the family bring in familiar items from the patient's home.

Correct Answer: C Rationale: Patients at risk for problems with safety require close supervision. Placing the patient near the nurse's station will allow nursing staff to observe the patient more closely. Use of "why" questions is frustrating for the patient with AD, who are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patient's short-term memory loss, reorientation will not help to prevent wandering behavior. Because the patient had wandering behavior at home, familiar objects will not prevent wandering. Cognitive Level: Application Text Reference: p. 1573 Nursing Process: Planning NCLEX: Safe and Effective Care Environment

A patient with Alzheimer's disease (AD) is hospitalized with a urinary tract infection. The spouse tells the nurse, "I am just exhausted from the constant care and worry. We don't have any children and we can't afford a nursing home. I don't know what to do." The most appropriate nursing diagnosis for the spouse is a. anxiety related to limited financial resources. b. ineffective health maintenance related to stress. c. caregiver role strain related to limited resources for caregiving. d. social isolation related to unrelieved caregiving responsibilities.

Correct Answer: C Rationale: The spouse's statements are most consistent with caregiver role strain. The other diagnoses each address one aspect of the spouse's problem, but caregiver-role strain related to limited resources for caregiving addresses all the information the nurse has about this situation. Cognitive Level: Application Text Reference: pp. 1574-1575 Nursing Process: Diagnosis NCLEX: Psychosocial Integrity

A 62-year-old patient is brought to the clinic by a family member who is concerned about the patient's increasing sleep disturbances and inability to solve common problems. To obtain information about the patient's current mental status, which question should the nurse ask the patient? a. "Where were you were born?" b. "Do have any feelings of sadness?" c. "What day of the week is it today?" d. "How positive is your self-image?"

Correct Answer: C Rationale: This question tests the patient's orientation to time, which is decreased in early Alzheimer's disease (AD) or dementia. Asking the patient about birthplace tests for remote memory, which is intact in the early stages. Questions about the patient's emotions and self-image are helpful in assessing emotional status, but they are not as helpful in assessing mental state. Cognitive Level: Application Text Reference: pp. 1564, 1567 Nursing Process: Assessment NCLEX: Physiological Integrity

A 71-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. variable ability to perform simple tasks. c. difficulty eating and swallowing. d. loss of recent and long-term memory.

Correct Answer: D Rationale: Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient's ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia. Cognitive Level: Application Text Reference: pp. 1562-1563 Nursing Process: Assessment NCLEX: Physiological Integrity

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

A client was admitted to the intensive care unit after a motor vehicle accident. The client sustained a right parietal injury, resulting in an acute confusional state or delirium. The client reports that there are "bugs crawling around" on the arms. The nurse understands this as:

tactile hallucinations from delirium.

An 80-year-old is brought to the clinic by the client's spouse. The client has a history of peripheral vascular disease and type 2 diabetes. The spouse states that the client hasn't seemed to be normal for the preceding few days, noting that the client has been lethargic and mildly confused at times and has been incontinent of urine. The spouse reports that the client's blood glucose levels have been elevated. The nurse considers which as the most likely explanation for the client's change in mental status?

Delirium related to underlying medical problem

A client with Alzheimer's disease in the intensive treatment unit repeatedly tries to go into other clients' rooms to nap during the day. The most appropriate nursing intervention for this client is what?

Escorting the client to the client's room for napping

A nurse is providing education to the care provider of a cognitively impaired client who is prescribed a cholinesterase inhibitor. Which information about medication side effects should the nurse be sure to include?

Gastrointestinal (GI) symptoms

A nurse is preparing a presentation for a group of staff nurses about neurocognitive disorders. When describing vascular neuorocognitive disorder, the nurse would identify which as posing the greatest risk for this disorder?

Hypertension

Which is the primary treatment for delirium?

Identify and treat any causal or contributing medical conditions

Which is the priority when caring for a client with delirium?

Identifying the cause

A nurse is caring for a client with delirium. The client sees a thermometer on the nurse's table and shouts, "Don't stab me!" and cowers. Which feature of delirium is this client exhibiting?

Illusion

Cognitive disorders are characterized by what?

Impaired attention, memory, and abstract thinking

Delirium can be differentiated from many other cognitive disorders in which way?

It has a rapid onset and is highly treatable if diagnosed quickly.

The client with dementia often cannot clearly communicate physical needs. Which intervention should the nurse teach the caregiver to address common physical problems?

Keep a record of bowel movements.

Which is the priority intervention for a client diagnosed with delirium?

Maintenance of safety

A client is exhibiting signs of mild delirium such as occasional confusion about why the client is in the hospital and what day of the week it is. When developing a care plan, the nurse identifies several strategies to improve the client's cognitive function. Which intervention will be helpful to the client?

Make up a daily calendar with the date and the times of scheduled activities.

A client with a medical diagnosis of dementia of Alzheimer's type has been increasingly agitated in recent days. As a result, the nurse has identified the nursing diagnosis of "risk for injury related to agitation and confusion" and an outcome of "the client will remain free from injury." What intervention should the nurse use in order to facilitate this outcome?

Monitor amount of environmental stimulation and adjust as needed.

While reviewing the medical record of a client with moderate dementia of the Alzheimer type, a nurse notes that the client has been receiving memantine. The nurse identifies this drug as which type?

N-methyl-D-aspartate (NMDA) receptor antagonist

A client has experienced a gradual flattening of affect, confusion, and withdrawal and has been diagnosed with Alzheimer's disease. The nurse assesses which additional characteristics of this disorder?

Personality change, wandering, and inability to perform purposeful movements

A client with dementia becomes extremely agitated shortly after being admitted to the psychiatric unit. The nurse is reluctant to use physical restraints to control the client. What is a likely reason the nurse has this reluctance?

Physical restraints may increase the client's agitation.

Which is an infection-related cause of delirium?

Pneumonia

A nurse's aide has rung the call light for assistance while providing a client's twice-weekly bath because the client became agitated and aggressive while being undressed. Knowing that the client has a diagnosis of Alzheimer's disease and is prone to agitation, which measure may help in preventing this client's agitation?

Reminding the client multiple times that he or she will be soon having a bath

A client with Alzheimer's disease has a nursing diagnosis of risk for injury related to memory loss, wandering, and disorientation. Which nursing intervention should appear in this client's care plan to prevent injury?

Remove hazards from the environment.

A client is diagnosed with dementia that has progressed significantly. Which would be the priority for this client?

Safety

The client is 79 years old and has been diagnosed with dementia. Continuing assessment reveals that the client's condition is progressing significantly. Which would be the priority when providing care?

Safety

Which would be the priority goal for a client with dementia?

Safety

Which can be identified as a hallmark symptom of dementia?

Short-term memory loss

The nurse receives a report that a 75-year-old client is recovering from surgery. During the shift, the nurse notes that the client is forgetful and restless. Several times, the client calls the nurse the name of the client's daughter. The nurse interprets this behavior as what?

Signs of delirium

The client is 42 years old, married, and has two children, ages 16 and 18. The client is also caring for the client's parent, who is in the late stages of Alzheimer's disease. The nurse would want to assess the client for what?

Signs of stress

A client is diagnosed with dementia related to Parkinson's disease. While at a doctor's visit, a cholinesterase inhibitor is prescribed for the client. The nurse knows that this type of medication would be prescribed for the client to do what?

Slow deterioration of memory and function

The psychiatric nurse documents that the cognitively impaired client is exhibiting "confabulation" when observed doing what?

Telling other clients that the client "was a dairy farmer" when the client actually ran a small grocery store

The client has early Alzheimer's disease. When asked about family history, the client relates that the client has two children who are both grown and who visit the client around the holidays each year. The nurse subsequently discovers that the client has one child who is currently assigned overseas and who has not been home for 2 years. Which would best describe the client's behavior?

The client is confabulating, most likely to cover for memory deficit.

The diagnosis of delirium is supported when the nurse notes which in the client?

The is convinced that the client sees "hundreds" of bugs and is not always oriented to time and place

A 59-year-old has just been diagnosed with early-stage dementia. The client is experiencing mild forgetfulness but can function normally. The client lives with a spouse and adult child, who is a single parent of two. When planning care for this family, which of the goals should the nurse identify as a priority?

The client will discuss emotional response to diagnosis.

An 82-year-old client with a diagnosis of vascular dementia has been admitted to the geriatric psychiatry unit of the hospital. In planning the care of this client, which outcome should the nurse prioritize?

The client will remain free from injury.

A group of friends have arrived at the hospital to visit a client recently diagnosed with delirium. The nurse tells the friends they can visit with the client one at a time. What is the likely reason for the nurse to give this instruction?

The nurse wants to prevent increasing the client's confusion.

The nurse preparing an educational program on dementia should include which information?

The onset of symptoms of dementia is gradual

A nurse is caring for a client with delirium. The nurse assesses the client's activities of daily living on a daily basis. What is the most likely reason for assessing these so frequently?

To assess for fluctuation in the client's capabilities

A nurse is studying the medical chart of a client with delirium. The nurse finds that the client was given haloperidol. What would be the most likely reason for administering this drug to the client?

To decrease agitation

The nurse is working with the family of a client who is newly diagnosed with Alzheimer's type dementia. Which suggestion would be effective for assisting the family members in daily orienting of their family member when the client returns home?

Use daily newspapers, calendars, and a set routine.

Which type of hallucination is most commonly seen in clients diagnosed with delirium?

Visual

Which client behavior should the nurse attempt to change when managing a client's tendency to wander and pace at night?

take a nap mid afternoon and before dinner

The nurse documents that a client diagnosed with dementia of the Alzheimer's type is exhibiting agnosia when the client is observed being unable to ...

identify a picture of a car.

What is the greatest benefit support groups provide to the caregivers of clients diagnosed with dementia?

provides interaction with those with similar concerns

The nurse should consider the intervention referred to as "going along with" when managing the care of which client?

the older widower who is worried about his wife not being able to visit because of the snow