Delirium and Dementia, Immobility

Patient is having trouble falling asleep. Which is the most appropriate nursing intervention to help this patient fall asleep? a) pain medication and watching movies. b) a back rub, a glass of milk and soothing conversation. c) a sedative and reality orientation. d) a walk followed by a shower.

b) a back rub, a glass of milk and soothing conversation.

The patient with dementia has not been sleeping for three days. Which sleeping aid medication is expected to be prescribed by the physician? a. haloperidol. b. Trazodone. c. donazepil. d. carbamazepine.

trazodone.

What are the adaptations that the Cognitive Developmental Approach (CDA) design in caring for patients with dementia achieve? a. Increase cognitive abilities. b. Adapt environment to patient. c. Offer a wide variety of choices. d. Abolish irrational fears.

Adapt environment to patient (The CDA adapts implementations based on the patient's cognitive abilities as they are, modifies the environment, and offers limited choices).

A patient asks a nurse what causes dementia. What two most prevalent types of dementia should the nurse consider before responding? a. Pick disease and Huntington disease. b. Alzheimer disease and vascular dementia. c. vascular dementia and Huntington disease. d. Creutzfeldt-Jakob disease and Pick disease.

Alzheimer disease and vascular dementia

Patient in traction with a fractured hip is diagnosed with a stage I pressure ulcer. She asks the nurse how a pressure ulcer could occur after only 2 days of immobility. On what knowledge should the nurse base a response? a. Erythema can occur in 1 to 2 hours even in a person with healthy skin and adequate circulation. b. It takes several days for a pressure ulcer to form. c. The pressure ulcer probably occurred when you fell. d. The cause of pressure ulcers isn't really known.

a) Erythema can occur in 1 to 2 hours even in a person with healthy skin and adequate circulation.

Which of the following are treatment for delirium except? a. use benzodiazepines in agitated older adults. b. antimicrobial if infection is the cause of delirium. c. managing the symptoms. d. treating and removing the cause.

a. use benzodiazepines in agitated older adults. (Antibiotic therapy; Although delirium may be a result of an infection, antibiotic therapy is not known to cause cognitive)

Nurse is gathering information from the family of a patient who is experiencing confusion. what important question should the nurse ask the family? a) "Are you sure she is confused? Maybe she just didn't hear what you were saying." b) "When did you first think she might be confused? Tell me exactly what happened." c) "Did something bad happen to her during her childhood?" d) "How can you say she is confused? She knows who she is."

b) "When did you first think she might be confused? Tell me exactly what happened."

A nursing assistant is bathing a patient who has a stage I pressure ulcer on the right shoulder. What action by the health care team could cause that tissue to become more damaged? a. Positioning the patient on the left side. b. Massaging the reddened area. c. Cleaning the area with mild soap and water. d. Positioning the patient in a prone position

b. Massaging the reddened area

What should a nurse document when assessing a new pressure ulcer? (SATA) a. smoking history. b. precise measurement of the ulcer. c. amount and characteristics of the drainage. d. color of the ulcer. e. location of the wound and it's description.

b. precise measurement of the ulcer. c. amount and characteristics of the drainage. d. color of the ulcer. e. location of the wound and it's description. (Documentation should include the precise location, color, size, shape, and drainage, as well as treatment applications. TOP: Documentation of Pressure Ulcers KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort)

Constipation can develop in an immobilized patient due to _____. a. inability to perform the Valsalva maneuver. b. weakened muscle tone. c. fear of developing diarrhea d. fatigue

b. weakened muscle tone. (?)

The patient was diagnosed by the physician with frontotemporal dementia. Which of the following aspects are affected by this type of dementia? a. speech and hearing. b. temperature regulation and breathing. c. behavior and language. d. alertness and vision

behavior and language

"My doctor says I get confused sometimes because I have vascular dementia. What caused me to have that?" Most appropriate response by the nurse? a) "it is due to deficiency of dopamine". b)"it is probably some abnormal electrical activity in your brain" c) "it usually caused from damage to the brain cells because of inadequate blood supply, like a small stroke" d) "it is the presence of synuclein in the brain"

c) "it usually caused from damage to the brain cells because of inadequate blood supply, like a small stroke"

A nurse is taking a patient who has Alzheimer disease to the bathing room for a tub bath. The patient states "Please don't make me take a bath today. I am so afraid that I will be washed down the drain" What is the nurse's best response? a) "I am your nurse, and I will stay with you, so you shouldn't be afraid of your bath." b) "don't be silly; there's no way you would fit in the drain." c) "let's go back to your room, and I will bathe you there." d) "today is your day for a bath."

c) "let's go back to your room, and I will bathe you there."

Nurse is planning the nutritional needs for a patient with Alzheimer disease. What is the best plan to have the dietary department provide? a) Pureed diet to be fed with a syringe. b) Foods that the patient can cut up to keep busy and not lose interest in eating. c) Finger foods several times a day. d) High-protein liquid diet

c) Finger foods several times a day. (Small, frequent meals are less confusing to patients. Finger foods high in protein and carbohydrates allow patients to feed themselves more easily. DIF: Cognitive Level: Comprehension TOP: Nutritional Needs KEY: Nursing Process Step: Planning)

Most effective intervention to prevent constipation, patient sustained fractured femur and is currently in traction? a) get patient up and to the bathroom twice each day b) administer enemas each day until has bowel movement. c) encourage a high-fiber diet and increased amounts of fluids. e) administer pain medication to prevent pain during deficaton

c) encourage a high-fiber diet and increased amounts of fluids.

Nurse is providing discharge instructions to the family of an older adult patient who is unable to get out of bed. What should the nurse instruct the family regarding the most effective way to prevent urinary incontinence associated with immobility? a) restrict fluid intake to 500 mL per 24 hrs. b) avoid fluid intake during dinner and thereafter. c) set up toileting program. d) use absorbent underpads.

c) set up toileting program.

When preparing a plan care for an older patient, a nurse should consider the common problems associated with immobility. What should these problems be classified as? a. physical and psychosocial. b. environmental and intellectual. c. internal and external. d. mental and medical.

physical and psychosocial.

a 60 year old patient with pneumonia has thick secretions pooled in the lower respiratory structures. These secretions interfere with the: 1. circulation of blood in the extremities. 2. detoxification process in the liver. 3. exchange of white blood cells and red blood cells in the capillaries. 4. exchange of oxygen and carbon dioxide in the lungs.

4. exchange of oxygen and carbon dioxide in the lungs.

An 80 year old patient with delirium related to high fever is hallucination about large animals being in the room. What is the most reassuring to the patient? a. " Your are in the hospital. There are no animals in this room." b. "I'm going to turn off the lights so you won't have to look at the animals." c. "Yes, the animals are in here, but they are sound asleep." d. "The hospital does not allow animals in the room"

"Your are in the hospital. There are no animals in this room"

what are the common causes of delirium in older adults? (SATA) 1. infection. 2. fever. 3. drug effects 4. Lewy body disease 5. Parkinson's disease

1. infection. 2. fever. 3. drug effects. (Delirium is an acute state of confusion that can be caused by multiple factors such as surgery, infection, and drugs. The onset of delirium is usually quick. Reorienting the patient to reality is often a helpful nursing intervention. Delirium is managed by removing or treating the cause rather than focusing solely on a symptomatic treatment.)

what therapeutic reasons exist that explain why a patient might become immobile? (SATA) a. Reduction of the workload of the heart. b. Fear of falling. c. Reversal of the effects of gravity. d. Bereavement. e. Healing of a fracture.

A. Reduction of the workload of the heart C. Reversal of the effects of gravity E. Healing of a fracture (RATIONALE: A reduction of the heart's workload, a reversal of the effects of gravity (as in the treatment of a hernia or prolapse), and the healing of a fracture are all therapeutic reasons for immobilization. The fear of falling and bereavement are not therapeutic reasons).

During the shift report, a nurse is told that a patient she will be caring for has a stage II pressure ulcer. What should the nurse expect to visualize during the dressing change? A. Ulcer that appears black with possible signs of infection. B. Shallow ulcer that appears blistered, cracked, or abraded. C. Craterlike sore with a distinct outer margin formed as the epidermis thickens and rolls over the edge toward the ulcer base. D. Redness of skin with no ulceration.

B. Shallow ulcer that appears blistered, cracked, or abraded (RATIONALE: In a stage II pressure ulcer, some skin loss in the epidermis and dermis has occurred).

A nurse is admitting a patient who has been diagnosed as having confusion. What is the most important observation that the nurse should make regarding this patient? a. Eating, drinking, and sleeping patterns. b. Behavior, orientation, memory, and sleeping habits. c. Urinary and bowel elimination habits. d. Talking, walking, and sleeping patterns

Behavior, orientation, memory, and sleeping habits. (The first step in assessing a confusional state is to observe the patient's behavior, orientation, memory, and sleeping habits).

A nurse is assessing a patient for the possibility of confusion. What two major types of confusion should the nurse be aware of to appropriately assess this patient? a. Acute and chronic senility. b. Temporary and permanent confusion. c. Delirium and dementia. d. Senility and senile dementia

Delirium and dementia. (The two major types of confusion are acute confusional states, or delirium, and chronic confusion dementia).

what should the nurse be aware as the best prevention of immobility-related disorders? a) exercise. b) fluids. c) adequate fiber. d) dietary supplements.

Exercise

the care plan of an older adult patient states that the patient should be monitored while in the bathroom because of a history of vasovagal reflex. What should the nurse assess with this patient? a. Extremely elevated blood pressure after ambulation. b. Nausea and vomiting after a meal. c. Lightheadedness and fainting during defecation. d. Inability to urinate

Lightheadedness and fainting during defecation

For patient with pressure ulcers, the diet should be high in: 1. protein 2. minerals 3. potassium 4. fiber

Protein

A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. which of the following actions should the nurse take? a. massage the client's bony prominences. b. reposition the client at least every 2 hr. c. keep the head of the bed elevated. d. keep the client's skin most.

Reposition the client at least every 2 hr. (The nurse should change the client's position at least every 2 hr to stimulate circulation and prevent pressure ulcers).

What intervention is most appropriate to prevent respiratory complications resulting from immobility? A. Suction every 4 to 6 hours. B. Administer pain medications as frequently as possible. C. Teach the patient the technique of pursed lip breathing. D. Reposition the patient, and encourage him or her to cough and deep breathe at least every 2 hours.

Reposition the patient, and encourage him or her to cough and deep breathe at least every 2 hours (RATIONALE: When a person remains immobile or does not take deep breaths, thick secretions can accumulate and pool in the lower respiratory structures).

During a skin integrity assessment, a nurse notices an area on the right heel that is black with the exposure of bone and muscles, and draining purulent, foul-smelling exudates. How should the nurse document this as a pressure ulcer? a. stage I b. stage II c. stage III d. stage IV

Stage IV

A nurse has found a patient with delirium in other patients' rooms several times. What is the best action by the nurse? a. Firmly tell the patient that he must stay out of other patients' rooms and tell him to return to his room. b. Take him back to his room and put him in bed with the side rails up. c. Take him to the nurses' station and let him visit for a while. d. Administer a dose of lorazepam (Ativan) as ordered.

Take him to the nurses' station and let him visit for a while (Avoid using physical restraints, which tend to increase anxiety and agitation. Sitting at the nurses' station will allow the nurses to monitor his activity and frequently orient him to his surroundings).

a nurse transcribes a discharge order for the patient with left-sided weakness after having a stroke indicating to teach the patient to perform range-of-motion exercises on affected extremities. The patient asks why she needs to do range-of-motion exercises. What is the nurses best response? a. Because the physician has ordered it. b. You will regain full use of your arm and leg if you will do the exercises correctly. c. They prevent the muscles and tendons from shortening and becoming unmovable. d. It will give you something to do because you cant work anymore.

They prevent the muscles and tendons from shortening and becoming unmovable.

Which characteristics are most likely to be present in the patient with dementia? a) Forgets things relatively quickly and is usually unable to learn new things. b) Can remember new tasks but will forget any previously taught tasks. c) Cannot learn new information but will probably remember anything you ask about the past. d) Responds well to reality orientation and needs to have a flexible schedule.

a) Forgets things relatively quickly and is usually unable to learn new things. (Keeping in mind the following two important concepts when taking care of patients with dementia is helpful: (1) they usually forget things relatively quickly, and (2) they are usually unable to learn new things)

What action made by the nurse is inappropriate when positioning an immobile patient? a) always position patient on a 90° angle to prevent shearing force. b) use pillow or trochanter rolls to maintain proper positioning. c) ensure patient's knees and hip are not flexed. d) use footboards to keep feet at right angle to the legs.

a) always position patient on a 90° angle to prevent shearing force (Reduce shearing forces by maintaining the head of the bed at the lowest elevation consistent with medical conditions and restrictions. Teach client/caregiver to keep head of bed at or below 30°. Head of bed may be elevated for meals then lowered within one hour after the meal).

what are believed to be causes of Alzheimer disease? (SATA) a) amyloid deposits in the brain. b) excess of acetylcholine. c) neurofibrillary tangles. d) altered tau protein. e) series of small strokes

a) amyloid deposits in the brain. c) neurofibrillary tangles. d) altered tau protein.

A nurse in an assisted living facility is caring for a client who is in early stages of dementia. Client has been oriented to name and place and is always cooperative and compliant. Which is the most appropriate nursing action if the client refuses to take morning medications? a) ask the client to express her reasons for refusing the morning medications and document the event. b) notify the charge nurse of the need for evaluation of the client's level of competence. c) crush the pills, if not contraindicated, and hide them in client's applesauce. d) call family member and discuss about the importance of adherence by telling him the possible implications of missing a dose. ​

a) ask the client to express her reasons for refusing the morning medications and document the event

Factors that increase risk for immobility in older adults?(SATA) a) chronic medical conditions. b) changes in posture and gait. c) financial resources. d) pain e) decreased in flexibility and strength.

a) chronic medical condition. b) changes in posture and gait. d) pain. e) decreased in flexibility and strength. (Slides pg:5,6 Immobility)

Patient with mild neurocognitive disorder is exhibiting hallucinations, delusions and anxiety. Which of the following is the focus of the nursing interventions for this type of neurocognitive disorder? a) compensate the functions that are declining by assisting the patient in their impaired memory. b) medicate the patient with antidepressants and antipsychotics. c) enroll the patient into alcohol and drug rehabilitation programs. d) request for the physician to prescribe Memantine.

a) compensate the functions that are declining by assisting the patient in their impaired memory. (?)

What instruction should the nurse include on performing isometric exercises? a) contract the muscle for several seconds, then relax the muscle or a few seconds, and contract it again. b) stand in front of a wall and push the arms allowing the elbow to be bent. c) have a family member perform full range-of-motion exercises on each of the patient's joints. d) perform full range-of-motion exercises of each joint.

a) contract the muscle for several seconds, then relax the muscle or a few seconds, and contract it again. (Isometric exercises involve tightening or tensing of muscles without moving body parts)

Charge nurse in a long-term care facility will be implementing a new protocol to meet the Joint Commission's National Safety Goal of preventing health care-associated pressure ulcers. When informing the staff nurses about the new standards, the nurse should emphasize that which of the following actions is the priority? a) identify the clients at greatest risk for developing pressure ulcers. b) turn and position each client every 2 hr. c) use barrier cream when performing perineal care d) identify the clients at greatest risk for development of pressure ulcers.

a) identify the clients at greatest risk for developing pressure ulcers.

The use of physical restraints should be avoided in patients with delirium because restraints tend to: a) increased anxiety. b) increased impaired thinking. c) disturb sleep patterns. d) disturb thought process.

a) increased anxiety.

Which of the following method of communication is effective in a confused patient? a) simple and direct b) open ended question c) confrontational d) offer variety of choices

a) simple and direct

A patient who has been prescribed bed rest x 1 week. Nurse notices reddened area on the patient's left hip. Skin intact; nurse presses but the redness does not fade. How should this area of pressure be classified? a) stage I b) stage II c) stage III d) stage IV

a) stage I. (The major characteristic of a stage I pressure ulcer is erythema (redness) that does not blanch when pressed. DIF: Cognitive Level: Analysis REF: p. 331 OBJ: 4 TOP: Stages of Pressure Areas KEY: Nursing Process Step: Assessment)

Nurse is assessing the sacral area of a immobile patient, nurse noted to have slough that covers the base of the ulcer. How should the nurse chart this observation? a) unstageable ulcer b) stage IV pressure ulcer c) stage III pressure ulcer d) suspected deep tissue injury

a) unstageable ulcer (Full thickness tissue loss in which the base of the ulcer is completely covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further Description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth and stage cannot be determined. However, it will be either a Stage III or IV. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed) ​

The nurse is taking care of three patients who are newly admitted to an assisted living facility. As the nurse collect data to assist in planning their care, the nurse focuses on prevention of pressure ulcers. What is the first step in the prevention of pressure ulcers? a. Identify patients at risk for developing pressure injuries. b. keep the bed linens dry, smooth, and free of wrinkles. c. use special mattress or bed designed to reduce pressure. d. reposition the patient in be at least every 2 hours

a. Identify patients at risk for developing pressure injuries

what negative effects does immobilization have on the musculoskeletal system? a. Demineralization of bone. b. Increase in aerobic capacity. c. Increased muscle oxidation. d. Lengthening of muscle fibers.

a. Demineralization of bone.

Patient complains that his "bottom" is sore. The nurse assesses the area and finds an open area on the sacrum that appears blistered. What action should the nurse implement? a) document the cause of the burn. b) clean with normal saline, pat it dry, and apply a light dressing to allow oxygen to pass through. c) massage the area to promote circulation. d) clean with alcohol, apply moisturizer and cover with a set dressing.

b) clean with normal saline, pat it dry, and apply a light dressing to allow oxygen to pass through. (RATIONALE: If pressure ulcers develop despite all preventive measures, proper and early treatment improves the chance for reversal. A stage II ulcer should be cleaned with mild soap and water or with sterile normal saline, patted dry, and covered with a dressing that allows airflow.)

To prevent the side effects of immobility, the nurse has been changing the position of the patient at least every 2 hours. What should the nurse do, If redness persists after 2 hours? (SATA) a) continue turning the patient every 2 hrs. b) maintain joints in their functional positions. c) increase fluid intake for this patient. d) shorten the interval between repositioning.

b) maintain joints in their functional positions. d) shorten the interval between repositioning. (2, 4 (p. 195)The patient's position should be changed at least every 2hours to prevent prolonged pressure on the skin. If red-ness from pressure persists after 2 hours, the interval between repositioning needs to be shortened. Maintain joints in their functional positions so that they are not abnormally flexed or extended)

What should the nurse instruct a patient in a wheelchair to do to decrease risk of pressure ulcers? a. Use a ring pillow on the seat of the chair. b. Lift the weight of the body using the arms of the wheelchair every 15 minutes. c. Scoot forward and back in the seat to stimulate circulation. d. Wear underwear that holds moisture close to skin.

b. Lift the weight of the body using the arms of the wheelchair every 15 minutes.

A patient has been admitted with a diagnosis of confusion. The physician's admission note states that he wants to assess for delirium versus dementia. What should the nurse be aware that the main differences include? a. Whereas delirium usually lasts several years, dementia lasts only a few days. b. Whereas delirium usually has sudden onset and is reversible, dementia is chronic and irreversible. c. Whereas dementia is usually caused by medications, delirium is not. d. Whereas dementia is easily treated with reality orientation, delirium is not.

b. Whereas delirium usually has sudden onset and is reversible, dementia is chronic and irreversible.

A patient with delirium repeatedly cries out for her husband. What is the most appropriate initial nursing intervention? a. Administer Haldol as ordered. b. Apply restraints so that the patient will not harm herself. c. Calmly tell the patient that she is in the hospital and that her husband is not there. d. Call the husband and tell him that he needs to come and stay with his wife.

c. Calmly tell the patient that she is in the hospital and that her husband is not there. (Anyone dealing with a delirious patient should be calm, warm, and reassuring. Frequent orientation to the surroundings and situation is important as well)

a nurse assesses a patient's risk for developing a pressure ulcer using the Norton scale. The patient's score is 20. What nursing action should be implemented? a. Call the physician immediately. b. Implement a pressure ulcer prevention program. c. Document the score. d. Order an alternating air mattress.

c. Document the score.

Patient is complaining to the nurse that he feels the need to have a bowel movement but has not been able to defecate. He had cramping and a small amount of brown watery stool. What should the nurse recognize these symptoms as? a. Diarrhea. b. Fecal incontinence. c. Fecal impaction. d. Flatulence.

c. Fecal impaction

A nurse's assessment reveals an area of erythema on an immobilized patient's sacrum. What is the initial nursing action? a. Apply a wet-to-dry dressing. b. Massage the reddened area. c. Reposition the patient. d. Rub the area with alcohol.

c. Reposition the patient.

A nurse is talking with a patient who recently became paraplegic as a result of a cervical spinal cord injury. When some home equipment is discussed, the patient becomes angry and says, I don't need to worry about any kind of home equipment. What is the best response by the nurse? a. I know you will be walking soon, but you may need some equipment until then. b. There is very little chance that you will ever walk. c. Tell me what it is about this equipment that bothers you. d. Let me call the physician to come explain your injuries to you.

c. Tell me what it is about this equipment that bothers you. (RATIONALE: The nurse should use therapeutic communication techniques to explore the patient's feelings).

nurse in a long-term care facility is taking a patient, diagnosed with delirium, to the dining room. Nurse asked the patient if she is ready to go eat lunch. Patient does not respond. What should be the nurse's next action? a) Take the patient by the arm and lead her to the dining room. b) Assist the patient to bed and bring her lunch to her. c) Tell the patient that she can go to the dining room whenever she gets hungry. d) Ask the patient again if she is ready to go eat lunch.

d) Ask the patient again if she is ready to go eat lunch. (A patient with delirium may have difficulty focusing or paying attention, and questions must often be repeated several times)

A nurse is performing a wet-to-dry dressing change on a stage 4 pressure ulcer. What is the purpose of this type of dressing? a)allow slough to grow. b) prevent infection. c) increase circulation to the tissue d) debride necrotic tissue

d) debride necrotic tissue (DÉBRIDEMENT OF NECROTIC TISSUE USUALLY FOR GRANULATION OF NEW, HEALTHY TISSUE)

Nurse is assisting with admission of a patient with confusion. What is the first step in collecting data about the confused patient? a) collect data for nutritional status of the patient. b) list all medication patient is taking. c) list any known acute or chronic illnesses. d) observe the behavior of the patient.

d) observe the behavior of the patient.

what is the most frequent site of skin breakdown? a) shoulder b) hip c) elbow d) sacrum

d) sacrum (The most frequent site of skin breakdown in the patient is the sacrum (35%). This is followed by heels (11%), ankles (3%), and scapulae (2%).

Nurse is preparing a room for a patient being transferred from the emergency department with a diagnosis of delirium. What type of room arrangement should the nurse make? a) dark and quiet. b) shared by another patient. c) brightly lit. d) visible from the nurse station.

d) visible from the nurse station.

the family of a patient with dementia expresses concern to the nurse about the patient wandering at night. They are afraid that the patient might get up and go outside while they are sleeping. What is the best advice for the nurse to provide to prevent the patient from being lost during the night? a. Apply a vest restraint at night. b. Perform constant reality orientation. c. Learn some behavior modification techniques. d. Put new locks on the outside doors in new places.

d. Put new locks on the outside doors in new places. (Take advantage of the fact that patients with dementia are usually unable to learn new things. They will probably not be able to figure out how to work a new lock. DIF: Cognitive Level: Application REF: p. 344-345 TOP: Dementia Safety KEY: Nursing Process Step: Implementation)

A nurse is caring for an older adult client who has dementia and wanders at night. Which of the following interventions should the nurse take? a. elevate the four side rails on the client's bed at night. b. assign the client to a quiet room away from the nurse's station. c. encourage the client to rest during the day. d. take the client to the bathroom on a regular schedule.

d. take the client to the bathroom on a regular schedule