Alterations In Cognition ATI
A nurse is caring for an older adult client who is experiencing confusion, disorientation, and agitation during an extended hospital stay. A family member asks the nurse what is happening to the client. Which of the following statements should the nurse include in the explanation to the family?
"Your loved one is likely experiencing changes in their perception due to the environment and stimuli. It may be best to keep them in a quiet room and limit visitors for now." This response by the nurse provides a reason for the changes in perception and offers a solution to reduce manifestations.
A nurse is assessing a client who has Lewy body dementia. Which response by the client's family about Lewy body dementia indicates a need for further teaching by the nurse?
"I know that the beta-amyloid plaques in the brain called Lewy bodies are what are causing all these issues." Beta-amyloid plaques and neurofibrillary tangles are two classic findings in clients with Alzheimer's disease, not in Lewy body dementia.
A nurse is teaching a client about the risk factors associated with late-onset Alzheimer's disease. Which statement by the client indicates the need for additional teaching by the nurse?
"I will eat healthier foods so that I can reduce my risk for developing Alzheimer's disease." A healthy diet and exercise are great strategies to help reduce risk for the development of Alzheimer's disease. However, this statement is not specific and would require additional questioning and teaching to ensure the right choices are made.
A nurse is caring for a client who has been recently diagnosed with Alzheimer's disease. A family member of the client asks the nurse what is causing the disease. Which of the following statements should the nurse include in their response?
"Plaque formation and tangles in the brain result in toxins building up. These things are causing brain damage to your loved one's brain." These changes are found in clients who have Alzheimer's disease. Beta-amyloid plaques and neurofibrillary tangles are attributed to the development of the manifestations of dementia.
The nurse is caring for a client who has dementia. Which of the following factors is the most common cause of dementia?
Alzheimer's disease the most common cause of dementia, accounting for 60% to 80% of the population with dementia.
A nurse is caring for a client who has suspected frontotemporal dementia. The nurse should anticipate providing safe care for which of the following types of cognitive changes in the client?
Behavior and language changes The nurse should identify that clients who have frontotemporal dementia experience changes in behavior, language, and emotions. The nurse should plan on maintaining a calm and positive environment and provide clear and simple information to the client.
A nurse has received a client from the PACU following abdominal surgery. The nurse should anticipate that the client is at risk for delirium due to which of the following risk factors? Select all that apply.
Blood loss during surgery is correct. Blood loss during surgery can cause fluid shifts and a potential lack of hemoglobin to transport oxygen to the brain. Anesthesia medications is correct. Anesthesia medications used during surgery may interfere with oxygen transport and metabolization in the brain. Young age is incorrect. An older adult client may be at an increased risk due to a response to medications and fluid and electrolyte imbalances. Male sex is incorrect. There is no evidence that one biological sex is at risk for delirium over the other. Fluid and electrolyte imbalance is correct. Fluid and electrolyte imbalances can occur before, during, and after surgery due to restrictions that may be placed on the client prior to surgery and increased amounts of fluid volume administered during surgery. These shifts can interfere with oxygen transport. Pain medications is correct. Pain medications used during surgery may interfere with oxygen transport and metabolization in the brain.
The nurse is educating the family members of a client who has dementia. The nurse should educate them about which of the following manifestations that indicate worsening dementia? Select all that apply.
Difficulty expressing ideas and finding appropriate words is correct. Worsening dementia may be indicated by changes to speech and language, difficulty carrying out tasks such as paying bills, loss of interest in activities, wandering and getting lost, and changes to balance and coordination. Difficulty with problem solving is correct. Worsening dementia may be indicated by changes to speech and language, difficulty carrying out tasks such as paying bills, loss of interest in activities, wandering and getting lost, and changes to balance and coordination. Withdrawal from activities that previously brought joy or purpose is correct. Worsening dementia may be indicated by changes to speech and language, difficulty carrying out tasks such as paying bills, loss of interest in activities, wandering and getting lost, and changes to balance and coordination. Difficulty maintaining balance and posture is correct. Worsening dementia may be indicated by changes to speech and language, difficulty carrying out tasks such as paying bills, loss of interest in activities, wandering and getting lost, and changes to balance and coordination. Occasionally forgetting why they entered a room is incorrect. Mild memory loss may be an initial manifestation that clients notice, but worsening dementia would be indicated by more frequent episodes of memory loss. Leaving the home and not remembering how to get back is correct. Worsening dementia may be indicated by changes to speech and language, difficulty carrying out tasks such as paying bills, loss of interest in activities, wandering and getting lost, and changes to balance and coordination.
A nurse is caring for a client in the ICU who is experiencing delirium. The nurse should recognize that the client may experience which of the following manifestations following the delirium episode?
Inability to remember events that occurred. A client who experiences delirium may have difficulty remembering what they said or how they acted during the episode of delirium.
A nurse is working with an interprofessional team to care for a client who has dementia and macular degeneration, resulting in impaired vision. Which of the following is the priority for the healthcare team and caregivers of the client?
Maintain independence and safety. The goal for caring for a client who has dementia and visual deficits should be to maintain independence while also ensuring safety.
A nurse is evaluating a client recently diagnosed with dementia and identifies that the client is fearful, quiet, and withdrawn. The nurse should recognize that the client is at risk for developing what other psychosocial manifestations? Select all that apply.
Mania is incorrect. Dementia does not impact a client's level of consciousness. Therefore, the client may be aware of the cognitive manifestations they are experiencing. This can create feelings of frustration, fear, sadness, and anxiety. Mania is associated with bipolar disorder, in which the client can experience changes in mood ranging from mania to depression. The client with dementia would not be at risk for mania. Depression is correct. Dementia does not impact a client's level of consciousness, and therefore, the client may be aware of the cognitive manifestations they are experiencing. This can create feelings of frustration, fear, sadness, and anxiety. Fear is correct. Dementia does not impact a client's level of consciousness, and therefore, the client may be aware of the cognitive manifestations they are experiencing. This can create feelings of frustration, fear, sadness, and anxiety. Social isolation is correct. Dementia does not impact a client's level of consciousness. Therefore, the client may be aware of the cognitive manifestations they are experiencing. This can create feelings of frustration, fear, sadness, and anxiety and lead to social isolation. Anxiety is correct. Dementia does not impact a client's level of consciousness, and therefore, the client may be aware of the cognitive manifestations they are experiencing. This can create feelings of frustration, fear, sadness, and anxiety.
A nurse is working with a client at the memory clinic who is suspected of having Alzheimer's disease. The nurse should recognize that the team should want to administer which of the following cognitive tests that is most inclusive to help with the diagnosis of Alzheimer's disease?
Mini-Mental State Examination (MMSE) The healthcare team may want to administer the MMSE to help evaluate the client's memory and other cognitive skills to help diagnosis Alzheimer's disease.
A nurse is caring for an older adult client experiencing delirium. The nurse should prioritize the need to assess and collaborate with the healthcare team quickly to do which of the following? Select all that apply.
Minimize complications to the client is correct. Considerations of the client should focus on quick and thorough assessment to determine if the client is experiencing delirium, a different type of medical emergency, or potentially a different type of cognitive alteration such as dementia. Determine if the client is experiencing a medical emergency is correct. Considerations of the client should focus on quick and thorough assessment to determine if the client is experiencing delirium, a different type of medical emergency, or potentially a different type of cognitive alteration such as dementia. Ensure the client is safe at all times is incorrect. Considerations of the client should focus on quick and thorough assessment to determine if the client is experiencing delirium, a different type of medical emergency, or potentially a different type of cognitive alteration such as dementia. Safety is important, but determining the cause of the delirium is a priority to prevent damage that can occur if not dealt with quickly. Rule out a different type of cognitive alteration, such as dementia is correct. Considerations of the client should focus on quick and thorough assessment to determine if the client is experiencing delirium, a different type of medical emergency, or potentially a different type of cognitive alteration such as dementia. Help the client remember what happened when they are better is incorrect. Considerations of the client should focus on quick and thorough assessment to determine if the client is experiencing delirium, a different type of medical emergency, or potentially a different type of cognitive alteration such as dementia. Once interventions are implemented, the nurse can evaluate the effectiveness of those interventions and help the client remember what happened during the episode if necessary,
A nurse in an outpatient clinic is assessing a client who presents with manifestations of problem-solving difficulties, changes in movement, and changes in language and emotions. Which of the following disorders should the nurse anticipate the client is experiencing?
Mixed Dementia The client is exhibiting manifestations consistent with two different types of dementia, which is referred to as mixed dementia. Problem-solving difficulties and mobility changes are consistent with Lewy body dementia. Changes with language and emotions are consistent with frontotemporal dementia.
A nurse is conducting a health history for a client at the physician's office. Which of the following factors in the client's history place the client at a greater risk for developing vascular dementia? Select all that apply.
Personal history of stroke is correct. Stroke, hematomas, and other disease processes that can cause vascular changes in the brain can lead to vascular dementia. A client who has a personal history of a stroke is therefore at an increased risk for experiencing vascular dementia. Personal history of subdural hematoma is correct. Stroke, hematomas, and other disease processes which can cause vascular changes in the brain can lead to vascular dementia. A client who has a personal history of a subdural hematoma has experienced a hematoma between the skull and the brain, creating pressure and potentially reducing blood flow within the brain. Therefore, the client is at an increased risk for experiencing vascular dementia. Family history of Alzheimer's disease is incorrect. A client who has a family history of Alzheimer's disease is at an increased risk for developing dementia caused by Alzheimer's disease, not by vascular dementia. Personal history of leukemia is incorrect. A client with a personal history of leukemia, a type of blood cancer, is not an increased risk for developing vascular dementia. The cancer did not change the flow of blood within the body and impact oxygen supply to the brain. Rather the blood cells that develop in leukemia are abnormal and cannot function as they should. Personal history of hypertension is correct. Stroke, hematomas, and other vascular disease processes in the brain can lead to vascular dementia. A client who has a personal history of hypertension, a known risk factor for the development of stroke, is at an increased risk for experiencing vascular dementia. Family history of sickle cell anemia is incorrect. Sickle cell anemia is an inherited disorder, which requires both parents to be carriers of the disease. If a client has a personal history of sickle cell anemia, which causes r
A nurse is planning care for a client who has dementia. Which of the following should the nurse recognize as a goal for the plan of care?
Promote independence for the client. The main goal of the plan of care should be to promote independence for the client for as long as possible.
A nurse is visiting the home of a client who has dementia and their partner. The nurse determines the client's partner is experiencing caregiver role strain. Which of the following interventions by the nurse are appropriate to help the caregiver build resilience? Select all that apply.
Provide information about community resources that can provide respite for the partner is correct. Providing information about community resources can help the partner of the client feel hopeful and build resilience. Encourage the partner to schedule time to go out with the client to an activity with their friends is incorrect. It is best to help the partner or caregiver find activities that bring them joy and schedule time for them to participate by themselves to build resilience and hope. Sit with the partner and make a list of individuals that live nearby that can be a part of a support system is correct. Helping the partner identify individuals that can be a part of a support system they can depend on can help build resilience and provide hope. Look for a relaxation or yoga class nearby that the partner can participate in to reduce stress is correct. Encouraging and educating about relaxation techniques the partner can incorporate can help reduce stress, build resilience, and provide hope. Help the partner meal plan so that healthy food choices can easily be incorporated into the day is correct. Healthy lifestyle factors can help the caregiver stay healthy and feel better, which can help build resilience and provide hope.
Flow Sheet 52-year-old client; Height 168 cm (5 feet 6 in); Weight 111.1 kg (245 lb) History of hypertension and hyperlipidemia Two days ago: Client presented to the hospital with worsening shortness of breath and complaints of chest pain. O2 sat 92% on room air. One day ago: Client admitted to the ICU after a coronary artery bypass graft surgery. Today: Client is in the ICU ready for transfer to the medical/surgical unit. Changes in behaviors noted. Client became agitated and confused after breakfast
Recognizing differences in cues can help the nurse differentiate between delirium and other cognitive disease processes. A client who has delirium will display manifestations that originate suddenly, over the course of a few hours to days. It is important to note the timeframe of the onset of manifestations as this is what differentiates delirium from other cognitive alterations, such as dementia. Manifestations of dementia are similar but will gradually appear over a period of months to possibly years. Clients experiencing delirium will have manifestations that change in severity back and forth. Manifestations of delirium include changes in the client's level of consciousness and perception, as well as confusion and disorientation, disorganized thinking and speech, anger, agitation, anxiety, depression, hallucinations, delusions, difficulty with memory recall and concentrating, and changes in sleep patterns. Most types of dementia are progressive diseases, meaning clients will manifest symptoms infrequently and less severely at first, but over time they will start having more frequent and severe manifestations. Some clients may display mild memory loss in which they forget where they placed an item or a word. As the disease process progresses, client's speech and language may change and they may begin to forget words more often, even for common objects, referring to them by unfamiliar names instead.
A nurse is caring for a client experiencing delirium in the ICU. Which of the following actions should the nurse take to reduce manifestations of confusion, agitation, and restlessness? Select all that apply.
Reduce excess noises is correct. Excess noises, such as beeping IV alarms and heart monitors, can create additional stimulation to the already agitated client. Restrain client to bed is incorrect. Restraining the client to the bed can cause additional safety concerns and increase agitation and restlessness. Restraints should be used only as a last option to keep patients safe. Administer sedative medications around-the-clock is incorrect. Sedative medications do not cure manifestations, but rather they mask them and contribute to manifestations of delirium as they wear off. Open the blinds during the day and close them at night is correct. Decreased environmental stimuli can cause increased confusion, agitation, and restlessness in a client. By opening the blinds during the day and closing them at night, the nurse is providing the client with outdoor exposure that can help reduce manifestations. Restrict visitors is incorrect. Limiting visitors can help decrease noise and overstimulation of a client. However, not allowing any visitors can cause more anxiety and confusion for a client who is in an unfamiliar place.
The nurse is visiting a client who has Alzheimer's disease who recently relocated to their child's home. The nurse is aware the client is at risk for experiencing which of the following conditions?
Relocation stress syndrome Relocation stress syndrome can cause manifestations in the client after changing their environment. This client is at risk due to the recent change in their environment of moving into their child's home.
A nurse is meeting the family of a client who has Alzheimer's disease. The nurse should discuss which of the following safety options with the family to keep the client safe at home?
Review lighting within the home to ensure it is adequate and remove excess cords and rugs. A client should be able to move freely about the home once all safety hazards have been addressed. Windows should be locked. There should be adequate lighting throughout the house, especially in the bedroom and bathroom. Avoid throw rugs and remove excess cords, which can trip the client. Labeling rooms, drawers, and cabinets can make it easier for the client to remember what they are looking for.
A nurse is planning care for a client who has dementia. Which of the following education topics are appropriate for the nurse to include in the plan of care? Select all that apply.
Safety considerations is correct. The role of the nurse should include providing a safe home environment and reducing safety concerns for the client and family. Stressors and responses is correct. Stressors and responses to stressors can vary from client to client. It is important to educate clients and their families about potential stressors and responses as well as to discuss known stressors and ways to respond to prompt positive client outcomes. Routine and socialization is correct. Regular routine can be beneficial and help clients with dementia. The need for socialization does not decrease when a client is diagnosed with dementia. Ways to incorporate both should be discussed and considered when building a plan of care. Dietary concerns is correct. There is not a special diet that clients with dementia should consume. However, as the disease progresses, the client's ability to eat and drink can be impacted. It may be beneficial for the nurse to discuss the changes that can occur as well as options for treatment if they do occur. Culture is incorrect. Culture can influence the plan of care. However, it is not an education topic that should be included in the plan of care.
A nurse is evaluating a client at the memory clinic who was referred for further testing for Alzheimer's disease. The nurse should anticipate which of the following laboratory test should be ordered?
Soluble amyloid beta protein precursor This laboratory test is used to aid in the diagnosis of Alzheimer's disease.
A nurse is caring for a client in the ICU. Which of the following manifestations exhibited by the client should the nurse recognize as manifestations of delirium?
The client is restless and appears anxious is correct. Agitation, hallucinations, and delusions may be manifestations that a client experiencing delirium suddenly exhibits. The client reports hearing voices that are not real is correct. Agitation, hallucinations, delusions may be manifestations that a client experiencing delirium suddenly exhibits. The client tells the nurse, "I am a king." is correct. Agitation, hallucinations, delusions may be manifestations that a client experiencing delirium suddenly exhibits. The client is confused and does not know their location is correct. A client experiencing delirium may have changes in their level of consciousness, including confusion and disorientation. The client sleeps through the night without waking is incorrect. A client experiencing delirium may exhibit changes in sleep patterns.
A nurse is caring for a client who has suspected early-onset Alzheimer's disease. Which part of the client's history is considered a risk factor for early-onset Alzheimer's disease?
The client has a trisomy 21. Individuals with trisomy 21 (Down syndrome) are at a greater risk for developing Alzheimer's disease earlier in life because they have an extra copy of the chromosome that is believed to cause increased buildup of beta-amyloid plaques and tau tangles.
A nurse in a long-term care facility is caring for a client who has Alzheimer's disease. The nurse notes that in the evenings the client becomes extremely agitated, yells, is confused, and is disoriented. The nurse should recognize these manifestations as consistent with sundowning as demonstrated by which of the following?
The presence of manifestations in the evening. During the episodes, the client becomes confused, disoriented, and yells. The nurse should recognize these behaviors are consistent with sundowning.
History and Physical Day 1: 67-year-old client admitted with right intertrochanteric fracture. Medical history: Diabetes mellitus type 2, hypertension, obesity, hyperlipidemia. Orthopedic and anesthesia consult. Labs pending. Admit to surgical unit. Day 2: Operative note: Open reduction internal fixation repair to right intertrochanteric fracture under general anesthesia. Vital signs remained stable throughout surgery. Incision closed and well approximated. Day 3: Client somnolent. Physical therapy reports client was up in chair last evening but was confused and unable to participate in therapy this morning. Incision dry and intact. Pedal pulses 2+ bilaterally. Day 4: 67-year-old client admitted with right intertrochanteric fracture underwent open reduction internal fixation repair two days ago. Physical therapy reports client unable to participate in therapy due to confusion and inability to follow directions
When analyzing cues for a client who has altered mentation, the nurse should consider findings to determine possible causes. The nurse should identify that the changes in client mentation occurred postoperatively, potentially resulting from the surgical procedure to repair the hip fracture. Another finding in support of delirium is the onset of confusion. The client was alert and oriented to person, place, time, and situation prior to surgery. Postoperatively, the client's orientation to time and situation were absent and the orientation to situation varied. This fluctuation in mentation indicates the client may be experiencing delirium. Changes in mentation can also occur with dementia, although this usually occurs gradually and may be attributed to health disorder such as hypertension. Hyponatremia may also impact a client's neurological status and cause confusion. However, hyponatremia didn't occur until day 4 but the confusion started postoperatively.
History and Physical • 71-year-old; Height 157 cm (5 feet 2 in), Weight 46.3 kg (102 lb) • Married; lives at home; spouse is primary caregiver • History of Alzheimer's disease for 3 years; last follow-up appointment at memory care clinic was 5 months ago • History of hyperlipidemia and anemia • Medications: Donepezil
When evaluating outcomes for a client with Alzheimer's disease who is wandering, the nurse should anticipate collaboration with the caregiver to ensure safety interventions are appropriate to help reduce wandering. The nurse should discuss with the client installing locks on the doors and windows out of sight of the client. Camouflaging doors with paint or curtains can keep the client from using them to leave the home. The spouse should consider installing an alarm or motion device to notify them if the client tries to open the door and leave the home. Avoid busy, crowded places that can cause disorientation, as this can lead to wandering behaviors. Nonessential interventions for wandering include removing throw rugs, wires and cords, installing handrails in bathroom around the toilet and in the shower, and checking the water temperature on the hot water heater to keep the client from scalding themselves. These interventions are important for environmental safety concerns