Medsurg ch. 59 Dementia and delirium
A patient is diagnosed with delirium using the Confusion Assessment Method (CAM). As a next step, what should the nurse consider to determine the reason for the patient's change in mental status? Select all that apply. Employment history Previous health history Serum electrolyte values Current living arrangements Medications routinely taken
Previous health history Serum electrolyte values Medications routinely taken Rationale Once delirium has been diagnosed, potential causes should be explored by evaluating health history, serum electrolytes, and the medication record. Employment history and current living arrangements are not identified as essential when determining the cause for delirium. p. 1415
A patient has been diagnosed with familial Alzheimer's disease. What characteristics are different in familial Alzheimer's disease when compared with those of sporadic disease? Select all that apply. A rapid disease course Presence of amyloid plaques Loss of connections between neurons A clear pattern of inheritance within the family An early onset of the disease (before 60 years of age)
A rapid disease course A clear pattern of inheritance within the family An early onset of the disease (before 60 years of age) Rationale Familial Alzheimer's disease is characterized by a rapid disease course and a clear pattern of inheritance within the family. The disease onset is also early (before the age of 60 years). The presence of amyloid plaques and loss of connections between neurons are common characteristics in familial as well as sporadic Alzheimer's disease. p. 1402
A patient with Alzheimer's disease is being treated in a long-term care facility. What is the role of a licensed practical nurse in caring for this patient? Select all that apply. Administer the ordered drug therapy. Provide personal hygiene, skin care, and oral care. Use bed alarms and surveillance to decrease risk for falls. Teach the patient and caregivers memory enhancement aids. Administer enteral feedings to patients who are unable to swallow.
Administer the ordered drug therapy. Administer enteral feedings to patients who are unable to swallow. Rationale The role of a licensed practical/vocational nurse is to administer the prescribed drug therapy, to administer enteral feedings to patients with swallowing difficulties, to check the patient's environment for safety, and to monitor any behavioral changes that indicate physiologic problems. Providing personal hygiene, performing skin and oral care, and using bed alarms and surveillance are done by unlicensed assistive personnel. Teaching the patient and caregivers memory enhancement aids is a role for a registered nurse. p. 1412
After reviewing assessment data, the nurse adds interventions to a patient's plan of care to address the risk for developing delirium. What findings caused the nurse to make the additions? Select all that apply. Age 84 Left foot wound Chronic renal failure Macular degeneration Previous hip replacement
Age 84 Left foot wound Chronic renal failure Macular degeneration Rationale Prevention of delirium involves recognition of high-risk patients. Patient groups at risk include those with advanced age, severe acute illness such as a foot wound, chronic renal disease, and visual impairment such as macular degeneration. Previous surgeries do not contribute to the development of delirium. p. 1415
When a patient with Alzheimer's disease is in severe pain but cannot communicate of which symptoms should a nurse be observant to recognize pain? Select all that apply. Agitation Wandering Withdrawal Sundowning Increased vocalization
Agitation Withdrawal Increased vocalization Rationale Because of difficulties with oral and written language, patients with Alzheimer's disease may have difficulty expressing physical complaints, including pain. Pain can result in an alteration in the patient's behavior, such as increased vocalization, agitation, withdrawal, or changes in functioning. Wandering may be related to loss of memory or to the side effects of medications, or it may be an expression of a physical or emotional need, restlessness, curiosity, or stimuli that trigger memories of earlier routines. Sundowning is a specific type of agitation in which the patient becomes more confused and agitated in the late afternoon or evening. The cause of sundowning is unclear, but several theories propose that it is due to a disruption in circadian rhythm. Other possible causes include fatigue, being in an unfamiliar environment, noise, medications, reduced lighting, and sleep fragmentation. p. 1412
Which is the most common cause of dementia? The aging process Alzheimer's disease Opioid medications A genetic predisposition
Alzheimer's disease Rationale Alzheimer's disease (AD) is the most common cause of dementia. Although advanced age is a risk factor for dementia, it is not the most common cause. Opioid medications are often responsible for delirium, not dementia. Although some patients may have a genetic predisposition for dementia, this is not the most common cause. p. 1401
The nurse reviews the medical records of several patients that are seen in the clinic for annual health maintenance visits and identifies that which patient is at the highest risk for Alzheimer's disease (AD)? A 65-year-old Asian American male An 80-year-old African American female An 85-year-oid Hispanic American male A 55-year-old Hispanic American female
An 80-year-old African American female Rationale AD is not a normal part of aging but, as with other forms of dementia, age is the most important risk factor for developing AD. Only a small percentage of people younger than 60 years old develop AD. The incidence of AD is slightly higher in African Americans and Hispanic Americans than in whites. Based on these data, the 80-year-old African American female patient is at the greatest risk for developing AD. The incidence of AD for Asian American patients is not as high as the African American and Hispanic American patients' risk. Although the incidence of AD for the Hispanic American patients is slightly higher than whites, male patients have a lower risk than female patients. Because the Hispanic American female patient is under 60 years of age, the risk for this patient is low for developing Alzheimer's disease. p. 1402
The nurse is caring for the patient with Alzheimer's disease (AD). The family asks the nurse how their family member got the condition. What response by the nurse is most appropriate? Long-term illegal drug abuse always leads to AD. Low cholesterol levels can make the dementia worse. Malnutrition can increase your chances of getting the disease. Diabetes greatly increases a person's chances of developing AD.
Diabetes greatly increases a person's chances of developing AD. Rationale Diabetes is a dramatic risk factor to people with dementia. Insulin resistance associated with diabetes interferes with how the body breaks down protein amyloid plaques found in the brain tissue of AD patients. Obesity, not malnutrition and high cholesterol, are also risk factors. Long-term drug abuse is not a known risk factor in developing the disease. Test-Taking Tip: Because few things in life are absolute without exceptions, avoid selecting answers that include words such as always, never, all, every, and none. Answers containing these key words are rarely correct. p. 1403
The nurse is providing discharge teaching to the family of a patient who is diagnosed with Alzheimer's disease (AD). Which interventions are appropriate for the nurse to recommend to enhance the patient's safety within the home environment? Select all that apply. Increasing fluid intake Ensuring a well-lit stairwell Tacking down carpet edges Installing grab rails by the toilet Placing throw rugs on hardwood flooring
Ensuring a well-lit stairwell Tacking down carpet edges Installing grab rails by the toilet Rationale Interventions that are appropriate to enhance safety for the patient diagnosed with AD in the home environment include having stairwells well lit, tacking down carpet edges, and installing grab rails by the toilet. The use of throw rugs is a safety hazard and this is not recommended. Although increasing fluid intake is appropriate for the patient with AD, this is an intervention to decrease the patient's risk for infection, not to promote safety within the home environment. p. 1412
A patient in the coronary care unit begins to exhibit signs of delirium. The nurse identifies that which factors may have contributed to the acute onset of symptoms? Select all that apply. Hard of hearing History of heart failure Indwelling urinary catheter Intravenous fluid administration Anesthesia for pacemaker insertion surgery
Hard of hearing History of heart failure Anesthesia for pacemaker insertion surgery Rationale Delirium can occur after a relatively minor insult in a vulnerable patient. Underlying health problems such as heart failure or sensory limitations may contribute to the development of delirium. In other patients it may take a combination of factors such as anesthesia and surgery to precipitate delirium. For this patient, a hearing deficit, history of heart failure, and anesthesia for pacemaker insertion can be identified as factors contributing to the development of delirium. An indwelling urinary catheter and intravenous fluid administration are not identified as precipitating factors for delirium. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 1415
Select the appropriate manner to interact with an older adult patient who recently became confused and agitated in the intensive care unit. Select all that apply. Correct any misstatements made by the patient. Have a calm and reassuring approach with the patient. Turn the television on in the room to distract the patient. Reorient the patient and have clock and calendar visible to the patient. Make sure the patient is wearing his or her own eyeglasses and hearing aids.
Have a calm and reassuring approach with the patient. Reorient the patient and have clock and calendar visible to the patient. Make sure the patient is wearing his or her own eyeglasses and hearing aids. Rationale The patient has developed delirium, which is common among elderly patients in intensive care units. A calm, reassuring approach enhances a feeling of security. Wearing eye glasses 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. p. 1414
What nursing interventions are appropriate for unlicensed assistive personnel when taking care of patients with Alzheimer's disease? Select all that apply. Help patients with eating Monitor the behavioral changes Assist patients with daily activities Use bed alarms and surveillance to decrease risk of falls Teach patient and caregivers memory enhancement aids
Help patients with eating Assist patients with daily activities Use bed alarms and surveillance to decrease risk of falls Rationale All staff members who care for a patient with Alzheimer's disease are responsible for ensuring the patient's physiologic and psychosocial safety. The roles of unlicensed assistive personnel are to help patients with eating and to assist with their daily activities. The use of bed alarms and surveillance will help to decrease the risk of falls in such patients. Monitoring the behavioral changes and teaching the patient and caregivers memory enhancement aids are roles of the registered nurse. pp. 1411-1412
A patient with diabetes mellitus wishes to know why diabetes increases the risk of developing dementia. How should the nurse explain this connection to the patient? High blood glucose eliminates oxidative stress that damages cells. Insulin resistance promotes the body's ability to break down amyloid. High glucose levels reduce cholesterol levels, preventing atherosclerosis. High glucose levels cause microangiopathy, which damages blood vessels of the brain.
High glucose levels cause microangiopathy, which damages blood vessels of the brain. Rationale Diabetes is one of the major risk factors of dementia. Diabetes mellitus damages the small vessels throughout the body, including those of the brain. A compromised oxygen supply due to these damaged blood vessels may be responsible for progressive cognitive decline in patients with diabetes mellitus. Insulin resistance does not promote the body's ability to break down amyloid; rather, it interferes with it. Amyloid protein is responsible for forming brain plaques in Alzheimer's disease. High blood glucose does not eliminate oxidative stress; it produces oxygen-containing molecules that can damage cells. In addition, high blood glucose, coupled with high cholesterol, accelerates atherosclerosis, which contributes to vascular dementia. Test-Taking Tip: Do not panic while taking an exam! Panic will only increase your anxiety. Stop for a moment, close your eyes, take a few deep breaths, and resume review of the question. p. 1403
Which statement is true regarding the pathophysiology of Alzheimer's disease (AD)? Plaques and neurofibrillary tangles are unique to patients with AD. Neurofibrillary tangles are absent on the neurons of patients with AD. By the final stage of AD, the patient's brain tissue is significantly enlarged. In patients diagnosed with AD, more plaques appear in certain parts of the brain.
In patients diagnosed with AD, more plaques appear in certain parts of the brain. Rationale In patients diagnosed with AD, more plaques appear in certain parts of the brain. By the final stage of AD, brain tissue is significantly atrophied, not enlarged. Plaques are not unique to patients with AD. Neurofibrillary triangles are present, not absent, on the neurons of patients with AD. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. p. 1403
A nurse is teaching a group of caregivers to manage a patient in a late stage of Alzheimer's disease. What are the instructions that the nurse should include? Select all that apply. Do not correct misstatements. Get the person to stop driving. Provide a regular schedule for toileting. Continue communication through talking and touching. Register with MedicAlert and Alzheimer's Association Safe Return.
Provide a regular schedule for toileting. Continue communication through talking and touching Rationale In the late stage of Alzheimer's disease, the patient has profound loss of memory and cognition and may be confined to bed. The patient requires help in activities of daily living. The patient should be provided with a regular schedule for toileting to reduce incontinence. Communication should be done through talking and touching. Not correcting misstatements and registering with MedicAlert and Alzheimer's Association Safe Return are appropriate interventions when the patient is in earlier stages, but by the late stages, they usually don't apply, because the patient's abilities to talk and wander are highly impaired. Getting the patient to stop driving is also an appropriate intervention in earlier stages, but irrelevant in late stages, because by this time the patient's impairments have long since precluded driving. Test-Taking Tip: The following are crucial requisites for doing well on the NCLEX exam: (1) A sound understanding of the subject; (2) The ability to follow explicitly the directions given at the beginning of the test; (3) The ability to comprehend what is read; (4) The patience to read each question and set of options carefully before deciding how to answer the question; (5) The ability to use the computer correctly to record answers; (6) The determination to do well; (7) A degree of confidence. p. 1414
A patient with Alzheimer's disease has difficulty eating and swallowing. What nursing interventions are appropriate to help this patient? Select all that apply. Use easy-grip utensils Provide food in a crowded room Use pureed foods and thickened liquids Remind the patient to chew and swallow the food Encourage the patient to eat while watching television
Use easy-grip utensils Use pureed foods and thickened liquids Remind the patient to chew and swallow the food Rationale The patient with Alzheimer's disease with chewing and swallowing difficulty should be offered pureed foods and thickened liquids for ease of eating. Easy-grip eating utensils may allow the patient to self-feed. Patients may need reminders to chew their food and to swallow because they tend to forget and get distracted easily. Patients need a calm and peaceful environment for eating, so meals should not be served in crowded rooms. In addition, avoid distractions, such as watching television, while eating. Test-Taking Tip: Try putting questions and answers in your own words to test your understanding. p. 1412
A patient who has frontotemporal lobar degeneration has difficulty with verbal expression. What is the best advice the nurse can suggest to this patient's spouse to keep the patient safe during the day while the spouse is at work? Assisted living Adult day care Advance directives Monitor for behavioral changes
Adult day care Rationale To keep this patient safe during the day while the husband is at work, an adult day care facility would be the best choice. This patient would not need assisted living. Advance directives are important but are not related to her safety. Monitoring for behavioral changes will not keep her safe during the day. p. 1411
A patient is newly diagnosed with dementia with Lewy bodies. The nurse should monitor for which complications that are associated with the dementia? Select all that apply. Renal calculi Impaired mobility Impaired nutrition Pulmonary edema Difficulty swallowing
Impaired mobility Impaired nutrition Difficulty swallowing Rationale Nursing care for a patient with dementia with Lewy bodies relates to management of the dementia and of problems related to dysphagia and immobility. The patient is at risk for falls from impaired mobility and balance. Impaired nutrition is related to swallowing difficulties. Renal calculi and pulmonary edema are not health problems associated with dementia with Lewy bodies. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 1401
The nurse provides education to an adult patient who is diagnosed with early-onset Alzheimer's disease (AD). Which statement is appropriate for the nurse to include in the teaching session? "With proper treatment your AD will not advance for 10 years." "The type of AD with which you are diagnosed is the most common form of AD." "Your children should consider genetic testing to determine their risk for AD." "Any family member that tests positive for ApoE-4 will develop AD within five years." !
"Your children should consider genetic testing to determine their risk for AD." Rationale Patients who are diagnosed with early onset AD should encourage their adult children to be genetically tested for the disease process. The children of any patient diagnosed with early onset AD have a 50% risk for AD. Early onset AD is rare and it is often associated with a more rapid disease course. While proper treatment may slow the progression of AD it will continue to advance and is fatal. Most patients die from AD within 4 to 8 years of diagnosis. If a person tests positive for the apolipoprotein E-4 (ApoE-4) allele it does not mean that the person will develop AD. Test-Taking Tip: Key words or phrases in the question stem such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. No real absolutes exist in life; however, every rule has its exceptions, so answer with care. p. 1402
The nurse is caring for a hospitalized patient. Which observation does the nurse identify as a possible beginning sign of delirium? Pain level of 5 Awake at 3 AM Drop in blood pressure Reports of being hungry
Awake at 3 AM Rationale Early manifestations of delirium include insomnia. Being awake at 3 AM could indicate this early warning sign. Pain, hypotension, and increased hunger are not identified as manifestations of delirium. p. 1415
A nurse is caring for a patient with dementia with Lewy bodies. What symptoms should the nurse watch for? Select all that apply. > Blindness Muscle jerks Bradykinesia Hallucinations Fluctuating cognitive ability
Bradykinesia Hallucinations Fluctuating cognitive ability Rationale Patients having dementia with Lewy bodies typically have symptoms of Parkinsonism; these include extrapyramidal signs such as bradykinesia, rigidity, postural immobility, hallucinations, short-term memory loss, sleep disturbances, and unpredictable cognitive shifts. These patients do not present with muscle jerks and blindness; those symptoms indicate Creutzfeldt-Jakob disease caused by a prion protein. A prion is a small, pathogen-containing protein that is infectious (although it lacks nucleic acids). p. 1401
A nurse is caring for a patient who was alert and showed no signs of cognitive distress. Suddenly, the patient exhibited severe confusion and emotional distress. Which term describes this temporary state that could indicate a life-threatening syndrome? Delirium Dementia Mixed dementia Alzheimer disease
Delirium Rationale Delirium is defined as a state of temporary acute mental confusion that can be a life-threatening syndrome. Mixed dementia is characterized by the hallmark abnormalities of Alzheimer disease and another type of dementia. Alzheimer disease is a chronic progressive neurodegenerative disease of the brain. Dementia is a neurocognitive disorder characterized by dysfunction or loss of memory, orientation, attention, language, judgment, and reason. p. 1414
The child of an older patient states, "Since the discharge from the hospital two days ago, my parent won't eat and is confused." What does the nurse suspect is occurring with the patient? Delirium Infection Dementia Psychosis
Delirium Rationale In most patients, delirium usually develops over a two- to three-day period. Early manifestations of delirium include loss of appetite and confusion. Loss of appetite and confusion are not indications of an infection. Dementia has a slow, insidious onset. The described manifestations are not indicative of a psychiatric disorder. p. 1415
A nurse is teaching caregivers about the safety measures to reduce the risk of injuries for a patient with Alzheimer's disease. Which measures should be included in the teaching? Select all that apply. Have stairwells well lit Remove extension cords Tack down carpet edges Install handrails in the bath Plain mats to be used in tub or shower
Have stairwells well lit Remove extension cords Tack down carpet edges Install handrails in the bath Rationale Owing to the decline in cognitive functions in Alzheimer's disease, the patient may be unable to navigate physical spaces and interpret environmental cues. Therefore to ensure personal safety, the extension cords should be removed, the stairwell should be lit properly, and the carpet edges should be tacked down. Installing handrails in the bath may help prevent falls. Loose extension cords and use of plain mats increase the risk of falls. p. 1412
The nurse is conducting an assessment on a patient to rule out the diagnosis of Alzheimer's disease (AD). Which risks factors found in the patient's health history support the diagnosis of AD? Select all that apply. Osteoarthritis Hypertension Anorexia nervosa Diabetes insipidus Hypercholesterolemia
Hypertension Hypercholesterolemia Rationale Hypertension and hypercholesterolemia are both risk factors for dementia, including AD. Other risk factors include diabetes mellitus and obesity. Osteoarthritis, anorexia nervosa, and diabetes insipidus are not risk factors for AD. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. pp. 1401-1403
A patient with behavioral changes is scheduled for neurologic testing. Which findings does the nurse identify as supporting a diagnosis of dementia? Select all that apply. Loss of memory Early awakening from sleep Hyperactive body movements Difficulty with normal conversation Changes developing over the last few days
Loss of memory Changes developing over the last few days Rationale Dementia is often diagnosed when two or more brain functions, such as memory loss or language skills, are significantly impaired. Early awakening from sleep is associated with depression. Hyperactive body movements are associated with either dementia or delirium. Behavior changes that developed over the last few days are manifestations of delirium. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. pp. 1400-1401
A patient is diagnosed with frontotemporal lobar degeneration (FTLD). What assessment findings does the nurse expect? Select all that apply. Erratic behavior Altered memory Sleep disturbances Difficulty with speech Inconsistent motor function
Erratic behavior Altered memory Sleep disturbances Difficulty with speech Rationale In FTLD, portions of the frontal and temporal lobes atrophy. It is characterized by disturbances in behavior, memory, sleep, and it may include language impairment. Motor function changes are not identified as a manifestation of FTLD. p. 1401
A patient with Alzheimer's disease presents with increased vocalization and agitation. What do these symptoms indicate? Pain Glaucoma Lack of sleep Schizophrenia
Pain Rationale Patients with Alzheimer's 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. Lack of sleep, glaucoma, and schizophrenia do not usually present as agitation and increased vocalization. p. 1412
A nurse in a long-term care facility is caring for a patient with Alzheimer's disease. The patient, who is usually cooperative and calm, is agitated and refusing care from the nursing assistant. What action should the nurse do first? Notify the health care provider and obtain a medication to treat the agitation. Notify the patient's family and ask if someone could come and sit with the patient. Perform a physical assessment, including monitoring vital signs and signs of pain. Take the nursing assistant to the patient and explain that cooperation is expected.
Perform a physical assessment, including monitoring vital signs and signs of pain. Rationale Initially the nurse should assess the patient's physical status to determine if the patient is experiencing some physical ailment. Consider that the patient's dementia limits the ability to express needs. Precipitating factors causing the behavior change should be thoroughly investigated before asking a family member to sit with the patient or administering medication to control agitation. Attempting to reason with the patient will further agitate the patient. p. 1411
The family of a patient with dementia with Lewy bodies asks if the diagnosis has been confirmed. How should the nurse respond? "This type of dementia can never be confirmed." "A blood test was taken that confirmed the diagnosis." "Confirmation occurs by examining brain tissue after death." "The response to medications is used to confirm the diagnosis."
"Confirmation occurs by examining brain tissue after death." Rationale The diagnostic criteria for Lewy body dementia are based on clinical signs and symptoms and confirmed at autopsy by histologic examination of brain tissue. Lewy body dementia can be confirmed, but only after death. It is not confirmed by a blood test or by the patient's response to medications. p. 1401
For which patient should the nurse prioritize an assessment for depression? A patient in the early stages of Alzheimer's disease A patient who is in the final stages of Alzheimer's disease A patient experiencing delirium secondary to dehydration A patient who has become delirious following an atypical drug response
A patient in the early stages of Alzheimer's disease Rationale A patient in the early stages of Alzheimer's disease is particularly susceptible to depression because the patient is acutely aware of his or her cognitive changes and the expected disease trajectory. Delirium is typically a shorter-term health problem that does not typically pose a heightened risk of depression. p. 1411
A patient is diagnosed with Lewy body dementia. The nurse anticipates that which medication will be prescribed? Lisinopril Levodopa Methyldopa Warfarin sodium
Levodopa Rationale Medications for dementia with Lewy bodies (DLB) are determined on an individual basis and may include levodopa/carbidopa and acetylcholinesterase inhibitors. Lisinopril is an angiotensin-converting enzyme inhibitor used to treat heart failure and hypertension. Methyldopa is a medication used to treat cardiovascular and hypertension disorders. Warfarin sodium is an anticoagulant. p. 1401
A nurse is caring for a patient with Alzheimer's disease in a long-term care facility. What are the most common infections for which the nurse should be observant? Select all that apply. Pneumonia Skin infection Urinary tract infection Gastrointestinal infections Cerebrospinal fluid infection
Pneumonia Urinary tract infection Rationale Because of feeding and swallowing problems, the patient is at risk for aspiration pneumonia. Reduced fluid intake, prostate hyperplasia in men, poor hygiene, and urinary devices can predispose patients to bladder infections. The risk of a skin infection is increased in the later stages when the patient becomes confined to bed. Cerebrospinal fluid infection is uncommon. Gastrointestinal infection may happen but is not directly related to Alzheimer's disease. p. 1413
Which patient may face the greatest risk of developing delirium? A patient with fibromyalgia whose chronic pain recently has worsened A patient with a fracture who has spent the night in the emergency department An older patient whose recent computed tomography (CT) shows brain atrophy An older patient who takes multiple medications to treat various health problems
An older patient who takes multiple medications to treat various health problems Rationale Polypharmacy is implicated in many cases of delirium, and this phenomenon is especially common among older adults. Brain atrophy, if associated with cognitive changes, is indicative of dementia. Alterations in sleep and environment, as well as pain, may cause delirium, but this is less of a risk than in an older adult who takes multiple medications. p. 1415
A patient's dementia is suspected of having a vascular cause. Which diagnostic test does the nurse expect to be prescribed to validate this suspicion? Lipid panel CT scan of the brain Pituitary hormone levels Partial thromboplastin time
CT scan of the brain Rationale The diagnosis of dementia related to vascular causes is based on cognitive loss, vascular brain lesions demonstrated by neuroimaging techniques, and the exclusion of other causes of dementia. Therefore the nurse expects that a CT scan of the brain will be prescribed for this patient. A lipid panel, pituitary hormone levels, and partial thromboplastin time will not identify a vascular cause for this patient's dementia. p. 1401
What is the leading risk factor for delirium? Age Dementia Sleep deprivation Serious medical illness
Dementia Rationale The leading risk factor for delirium is dementia. Sleep deprivation has been linked to delirium, though it is not the leading risk factor. Many risk factors that can lead to delirium are more common in older patients, and older adults are more susceptible to drug-induced delirium, but age in and of itself is not a risk factor. Delirium may be a symptom of a serious medical illness. p. 1415
The nurse is teaching a group of caregivers about how to help patients with severe agitation in Alzheimer's disease. What are the teachings that the nurse should include in the plan? Select all that apply. Ignoring Distraction Redirection Restraining Reassurance
Distraction Redirection Reassurance Rationale Strategies that help to address difficult behavior include redirection, distraction, and reassurance. Redirecting involves changing the direction of the patient's focus and making the patient perform activities. Ways of distracting include taking a car ride, listening to music, looking at family photographs, or walking. Reassurance involves communicating to the patient that he or she is in a safe environment and protected from danger. Restraining and ignoring the patient will only make the situation worse. p. 1411
The nurse is preparing a staff education session about the association between dementia and diabetes mellitus. What is appropriate for the nurse to include? Select all that apply. Elevated blood glucose levels contribute to oxidative stress Insulin resistance may encourage the development of brain plaques Supplemental insulin alters arterial lining, encouraging atherosclerotic changes Uncontrolled glucose levels reduce the oxygen-carrying capacity of red blood cells Elevated glucose and cholesterol levels potentiate the development of atherosclerosis
Elevated blood glucose levels contribute to oxidative stress Insulin resistance may encourage the development of brain plaques Elevated glucose and cholesterol levels potentiate the development of atherosclerosis Rationale Diabetes can contribute to dementia in several ways. High blood glucose produces oxygen-containing molecules that can damage cells in a process known as oxidative stress. Insulin resistance, which causes high blood glucose and in some cases leads to type 2 diabetes, may interfere with the body's ability to break down amyloid, a protein that forms brain plaques in AD. High blood glucose along with high cholesterol has a role in atherosclerosis, which contributes to vascular dementia. Supplemental insulin is not identified as encouraging atherosclerotic changes. Uncontrolled glucose levels do not reduce the oxygen-carrying capacity of red blood cells. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 1403
Which professionals have a high risk of developing Alzheimer's disease or another type of dementia? Select all that apply. Fishermen Tennis players Football players Race car drivers Military members
Football players Race car drivers Military members Rationale Head trauma is a risk factor for dementia. Football players, military members, and race car drivers are at elevated risk of getting injured and eventually developing dementia. Tennis players and fishermen have a low risk of head trauma and therefore are at low risk of developing dementia related to their profession. p. 1403
Which nursing intervention is most appropriate when caring for patients with dementia? Avoid direct eye contact. Lovingly call the patient "honey" or "sweetie." Give simple directions, focusing on one thing at a time. Treat the patient according to his or her age-related behavior.
Give simple directions, focusing on one thing at a time. Rationale When dealing with patients with dementia, tasks should be simplified, giving directions using gestures or pictures and focusing on one thing at a time. The nurse should use gentle touch and direct eye contact. Calling the patient "honey" or "sweetie" can be condescending and does not demonstrate respect. It is best to treat these patients as adults, with respect and dignity, even when their behavior is childlike. p. 1414
The nurse is preparing to assess a patient with delirium. What actions should the nurse take when in the patient's room? Select all that apply. Greet the patient by name. Assist the patient in applying eyeglasses. Turn on the overhead lights for the patient. Gently touch the patient's arm when talking. Remind that patient that he or she is in the hospital.
Greet the patient by name. Assist the patient in applying eyeglasses. Gently touch the patient's arm when talking. Remind that patient that he or she is in the hospital. Rationale Personal contact through verbal communication is a reorienting strategy. The patient should be reoriented to place as necessary. Eyeglasses should be readily available because sensory deprivation can precipitate delirium. Personal contact through touch can be used as a reorientation strategy. Overhead lights may be excessive environmental stimuli and should be avoided. p. 1414
A spouse of a patient, just diagnosed with Alzheimer's disease in the mild stage, asks the nurse how to plan for the future and make treatment decisions. What is the best response by the nurse? Medicine is researching treatments for Alzheimer's disease actively and a cure may be near. Discussing advanced directives may cause the Alzheimer's disease to progress more quickly. Disease progression is uniform and decisions about treatment can be made after the patient is comfortable with the diagnosis. Health care decisions, including advanced directives, should be made while the patient is able to participate in the decision making.
Health care decisions, including advanced directives, should be made while the patient is able to participate in the decision making. Rationale The nurse should assist the spouse and patient to look at the future realistically and make health care decisions while the patient has the capacity to participate in the process. Progression of Alzheimer's disease varies with the individual. Offering the spouse a possible cure is false reassurance. The patient may not achieve a comfort level with the diagnosis. p. 1411
A nurse is caring for a patient who becomes agitated in the evening. What nursing interventions are most helpful? Select all that apply. Limiting caffeine intake Creating a calm environment Isolating the patient to minimize stimuli Consulting with the health care provider Allowing the patient to sleep for long hours
Limiting caffeine intake Creating a calm environment Consulting with the health care provider Rationale Creating a calm environment reduces agitation in the patient; restraining or threatening the patient can worsen the problem. Caffeine is a stimulant, so limiting caffeine intake would help in reducing agitation. Health care providers should be consulted if antianxiety drugs or sedatives need to be prescribed. Do not allow the patient to sleep for long hours at night, and limit daytime naps. Maximize the exposure to daylight rather than isolating the patient. p. 1411
The nurse is providing care to an adult patient that is diagnosed with mild Alzheimer's disease (AD). Which distraction activity is appropriate for the patient? Looking at family photos Looking at dangling ribbons Playing a board game appropriate for a school-age child Participating in an activity appropriate for the preschool-age child
Looking at family photos Rationale An appropriate distraction activity for an adult patient diagnosed with mild AD is looking at family photos. Activities appropriate for school-age and preschool-age children would be appropriate for a patient diagnosed with moderate AD. Looking at dangling ribbons is a distraction activity for a patient who is diagnosed with severe AD. Test-Taking Tip: Key words or phrases in the question stem such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. No real absolutes exist in life; however, every rule has its exceptions, so answer with care. p. 1411
The nurse recognizes that which intervention may be beneficial to a patient in the early stages of Alzheimer's disease (AD)? Admission to an AD unit Respite care once a week Use of antipsychotic drugs Memory aids such as calendars
Memory aids such as calendars Rationale For patients who are in the early stages of AD, memory aides such as the use of a calendar are often beneficial. Admission to an AD unit and weekly respite care may be appropriate as the disease progresses. Agitation and aggressive behavior do not typically occur in the early stages of AD; therefore the use of antipsychotic drugs is not appropriate. Antidepressants may be needed in the early stages of AD because many patients develop depression in this phase. p. 1411
The nurse is caring for an older adult patient. For what symptoms of dementia should the nurse be observant? Select all that apply. Seizures Dyspnea Memory loss Cognitive dysfunction Abrupt changes in behavior
Memory loss Cognitive dysfunction Abrupt changes in behavior Rationale In dementia, there is progressive neurodegeneration, and vascular changes lead to cognitive impairment. The cognitive impairment manifests as abrupt changes in behavior, memory loss, and cognitive dysfunction, 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. pp. 1400-1401
What does the letter "M" represent in the mnemonic, "DELIRIUM," to remember causes of delirium? Medication Malnutrition Memory loss Metabolic disorders
Metabolic disorders Rationale The letter "M" represents metabolic disorders in the mnemonic of causes for delirium. The "R" for Rx represents medication. The "D" for dementia and dehydration represents memory loss. Malnutrition is not part of this mnemonic. p. 1415
The nurse is providing care to an adult patient diagnosed with early-onset Alzheimer's disease (AD). The nurse recommends that the patient's children have genetic testing performed to determine the presence of which genes that are associated with AD? Select all that apply. Presenilin-1 (PSEN1) gene Presenilin-2 (PSEN2) gene Apolipoprotein E-2 (ApoE-2) allele Apolipoprotein E-4 (ApoE-4) allele Amyloid precursor protein (APP) gene
Presenilin-1 (PSEN1) gene Presenilin-2 (PSEN2) gene Amyloid precursor protein (APP) gene Rationale Early onset AD is associated with various mutations to the PSEN1 gene, the PSEN2 gene, and the APP gene. Late onset AD is associated with the presence of the ApoE-4 allele. The presence of the ApoE-2 allele is associated with a lower risk of AD. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 1402
During a home visit the nurse suspects that an older patient who was discharged after an emergency appendectomy is demonstrating signs of delirium. Which assessment information supports the nurse's suspicion? Rambling during the assessment Rating pain as a 3 on a scale from 0 to 10 Asking for information about permitted activity Requesting to have home visits in the afternoon
Rambling during the assessment Rationale Disorganized thinking exhibited by rambling is a characteristic of delirium. Delirium is one of the most frequent consequences of unscheduled surgery on the older adult, especially when the patient has not been stabilized physically or prepared emotionally. Pain level, asking for appropriate information, and discussing scheduling of home visits do not demonstrate characteristics of delirium. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response p. 1415
A patient with Alzheimer's disease is restless and agitated. How should a nurse help the patient? Select all that apply. Reassure the patient. Change the patient's focus. Call the health care provider. Do not ask the patient challenging "why" questions. Warn the patient to be calm or else restraints will be applied.
Reassure the patient. Change the patient's focus. Do not ask the patient challenging "why" questions. Rationale The agitated patient often cannot verbalize distress. In such a case, rephrase the patient's statement to validate its meaning and do not question the patient. For a patient who is agitated and restless, redirecting involves changing the patient's focus to perform other activities. Reassurance involves communicating to the patient that he or she will be protected from danger, harm, or embarrassment. Threatening the patient ("calm down or else") or calling the health care provider is likely to aggravate the behavior. Test-Taking Tip: The night before the examination you may wish to review some key concepts that you believe need additional time, but then relax and get a good night's sleep. Remember to set your alarm, allowing yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good breakfast, and arrive at the testing site at least 15 to 30 minutes early. p. 1411
A patient is diagnosed with dementia with Lewy bodies (DLB). In addition to dementia, which manifestations does the nurse expect the patient to exhibit? Select all that apply. Rigidity Flat affect Bradykinesia Hallucinations Postural instability
Rigidity Bradykinesia Hallucinations Postural instability Rationale Dementia with Lewy bodies (DLB) is a condition characterized by the presence of Lewy bodies in the brainstem and cortex. Patients typically have symptoms of Parkinsonism, hallucinations, short-term memory loss, unpredictable cognitive shifts, and sleep disturbances. A possible diagnosis of DLB is indicated by dementia plus two of the following symptoms: rigidity, bradykinesia, hallucinations, and postural instability. A flat affect is associated with Parkinsonism. p. 1401
What manifestations is the nurse likely to document when performing a physical assessment on a patient with dementia with Lewy bodies? Select all that apply. Rigidity Dementia Blindness Bradykinesia Postural instability Urinary incontinence
Rigidity Dementia Bradykinesia Postural instability Rationale Dementia with Lewy bodies is a condition characterized by the presence of Lewy bodies in the brainstem and cortex. Patients typically have symptoms of dementia and extrapyramidal signs such as bradykinesia, rigidity, and postural instability. Blindness is a clinical manifestation of Creutzfeldt-Jakob disease. Urinary incontinence can be a clinical manifestation of many diseases, including normal pressure hydrocephalus. p. 1401
A patient demonstrates beginning signs of delirium. Which of the following should the nurse investigate as a possible contributing factor to this new health problem? Triglycerides Vitamin D level Serum potassium International normalized ratio
Serum potassium Rationale Care of a patient with delirium focuses on eliminating precipitating factors, such as electrolyte imbalances. Of the choices listed, the one that can contribute to the development of delirium is serum potassium. Triglycerides, vitamin D, and international normalized ratio are not causes of delirium. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. p. 1415
A nurse is teaching a group of caregivers about the guidelines for caring for a patient with dementia. What are the guidelines that the nurse should include in the teaching? Select all that apply. Simplify tasks for easy understanding. Treat the patient with respect and dignity. Give directions using gestures or pictures. Remind the patient to hurry to counteract bradykinesia. Mandate participation in all activities or events to counteract social withdrawal.
Simplify tasks for easy understanding. Treat the patient with respect and dignity. Give directions using gestures or pictures. Rationale For easy understanding, focus on one thing at a time. Simplifying the tasks may also help the patient in understanding them and carrying out the tasks. Treat the patient with respect and dignity, even when the patient's behavior is childlike. Respect and dignity would encourage the patient to carry out self-care activities. When taking care of a patient with dementia, do not rush or hurry the patient or force the patient to participate in activities and events; such actions can make the patient agitated. p. 1414
The nurse is caring for a patient with progressive dementia who is being evaluated. Which finding supports frontotemporal lobar degeneration as the cause of the patient's symptoms? Onset of dementia at age 75 Frequent periods of remission Symmetrical atrophy of the temporal lobes Improvement with anticholinergic medication
Symmetrical atrophy of the temporal lobes Rationale Frontotemporal lobar degeneration (FTLD) is a clinical syndrome associated with shrinking of the frontal and temporal anterior lobes of the brain. The major distinguishing characteristic between this disorder and Alzheimer's disease is marked symmetric lobar atrophy of the temporal and/or frontal lobes. FTLD occurs between the ages of 40 and 70. The disease progresses relentlessly and does not have periods of remission. There is no specific treatment so medications will not improve the symptoms. p. 1401
The patient has been diagnosed with the mild cognitive impairment stage of Alzheimer's disease. What nursing interventions should the nurse expect to use with this patient? Treat disruptive behavior with antipsychotic drugs Use a calendar and family pictures as memory aids Use a writing board to communicate with the patient Use a wander guard mechanism to keep the patient in the area
Use a calendar and family pictures as memory aids Rationale The patient with mild cognitive impairment will have problems with memory, language, or other essential cognitive functions that are severe enough to be noticeable to others, but do not interfere with activities of daily living. A calendar and family pictures for memory aids will help this patient. This patient should not have disruptive behavior yet or get lost easily. Using a writing board will not help this patient with communication. p. 1411
The nurse is caring for a patient with Alzheimer's disease. Which pathophysiologic proteins are associated with Alzheimer's disease? Select all that apply. β-Amyloid Tau protein Pick bodies α-Synuclein Prion protein
β-Amyloid Tau protein Rationale β-Amyloid and tau proteins are associated with Alzheimer's disease. Development of plaques in the brain tissue is a part of aging; however, in patients with Alzheimer's disease, these plaques are seen in specific parts of the brain. These plaques are made up of clusters of insoluble deposits of a protein called β-amyloid, other proteins, remnants of neurons, nonnerve cells such as microglia, and other cells such as astrocytes. Tau proteins, through the microtubules, provide support to the intracellular structures in the central nervous system. In Alzheimer's disease, the tau protein is altered, which in turn causes the microtubules to twist together in a helical fashion. This twisting of microtubules results in formation of neurofibrillary tangles, a characteristic finding in the neurons of persons with Alzheimer's disease. Prion proteins are related to Creutzfeldt-Jakob disease, which is a rare and fatal brain disorder. Pick bodies are associated with frontotemporal lobar degeneration, which is a clinical syndrome associated with shrinking of the frontal and temporal anterior lobes of the brain. α-Synuclein is a protein associated with dementia with Lewy bodies in the brainstem and cortex. Lewy bodies are abnormal deposits of α-synuclein. p. 1403
