dementia delirium-Nclex
When administering a mental status examination to a patient, the nurse suspects depression when the patient responds with a. "I don't know." b. "Is that the right answer?" c. "Wait, let me think about that." d. "Who are those people over there?"
Correct Answer: A Rationale: Answers such as "I don't know" are more typical of depression. The response "Who are those people over there?" is more typical of the distraction seen in a patient with delirium. The remaining two answers are more typical of a patient with dementia.
The nurse has identified the nursing diagnosis of disturbed thought processes related to effects of dementia for a patient with late-stage Alzheimer's disease (AD). An appropriate intervention for this problem is to a. maintain a consistent daily routine for the patient's care. b. encourage the patient to discuss events from the past. c. reorient the patient to the date and time every few hours. d. provide the patient with current newspapers and magazines.
Correct Answer: A Rationale: Providing a consistent routine will decrease anxiety and confusion for the patient. In late-stage AD, the patient will not remember events from the past. Reorientation to time and place will not be helpful to the patient with late-stage AD. The patient with late-stage AD will not be able to read. Cognitive Level: Application Text Reference: p. 1571 Nursing Process: Planning NCLEX: Physiological Integrity
Risperidone (Risperdal) is prescribed for an outpatient with moderate Alzheimer's disease (AD). Which information obtained by the nurse at the next clinic appointment indicates that the medication is effective? a. The patient has less agitation. b. The patient is dressed appropriately. c. The patient is able to swallow a pill. d. The patient's speech is clearer.
Correct Answer: A Rationale: Risperidone is an antipsychotic used to treat the agitation, aggression, and behavioral problems associated with AD. The other improvements might occur with cholinesterase inhibitors. Cognitive Level: Application Text Reference: p. 1568 Nursing Process: Evaluation NCLEX: Physiological Integrity
When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse include? a. Reminding the patient frequently about being in the hospital b. Placing suction at the bedside to decrease the risk for aspiration c. Providing complete personal hygiene care for the patient d. Repositioning the patient frequently to avoid skin breakdown
Correct Answer: A Rationale: The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility. Cognitive Level: Application Text Reference: p. 1563 Nursing Process: Planning NCLEX: Physiological Integrity
A family member of a patient with possible Alzheimer's disease asks the nurse the purpose of the Mini-Mental State Examination (MMSE). Which response by the nurse is appropriate? a. The MMSE helps in establishing the diagnosis of Alzheimer's disease (AD). b. The MMSE is useful in determining the degree of mental impairment. c. The MMSE determines the choice of the most appropriate treatment. d. The MMSE aids in differentiating acute delirium from chronic dementia.
Correct Answer: B Rationale: The MMSE establishes the degree of mental impairment at the time it is given. It does not establish a diagnosis of AD but when given repeatedly over time may help to determine the progression of AD. The choice of treatment is made on the basis of multiple data, not just the MMSE. The MMSE may be abnormal with either delirium or dementia and is not useful in determining which condition the patient has. Cognitive Level: Application Text Reference: p. 1563 Nursing Process: Implementation NCLEX: Physiological Integrity
When teaching the spouse of a patient who is being evaluated for Alzheimer's disease (AD) about the disorder, the nurse explains that a. the most important risk factor for AD is a family history of the disorder. b. a diagnosis of AD can be made only when other causes of dementia have been ruled out. c. new drugs have been shown to reverse AD dramatically in some patients. d. the presence of brain atrophy detected by MRI confirms the diagnosis of AD in patients with dementia.
Correct Answer: B Rationale: The diagnosis of AD is one of exclusion. Age is the most important risk factor for development of AD. Drugs can slow the deterioration but do not dramatically reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in other diseases as well. Cognitive Level: Comprehension Text Reference: p. 1568 Nursing Process: Implementation NCLEX: Physiological Integrity
During the morning change-of-shift report at the long-term care facility, the nurse learns that the patient with dementia has had sundowning. Which nursing action should the nurse take while caring for the patient? a. Move the patient to a quieter room at night. b. Open the blinds in the patient's room and provide frequent activities. c. Have the patient take a brief mid-morning nap. d. Provide hourly orientation to time of day.
Correct Answer: B Rationale: The most likely cause of sundowning is a disruption in circadian rhythms and keeping the patient active and in daylight will help to reestablish a more normal circadian pattern. Moving the patient to a different room might increase confusion. Taking a nap will interfere with nighttime sleep. Hourly orientation will not be helpful in a patient with memory difficulties. Cognitive Level: Application Text Reference: p. 1573 Nursing Process: Implementation NCLEX: Safe and Effective Care Environment
To protect a patient from injury during an episode of delirium, the most appropriate action by the nurse is to a. have a close family member remain with the patient and provide reassurance. b. assign a staff member to stay with the patient and offer frequent reorientation. c. ask the health care provider about ordering an antipsychotic drug. d. secure the patient in bed with a soft chest restraint.
Correct Answer: B Rationale: The priority goal is to protect the patient from harm, and a staff member will be most experienced in providing safe care. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have multiple side effects. Restraints are sometimes used but tend to increase agitation and disorientation. Cognitive Level: Application Text Reference: p. 1577 Nursing Process: Implementation NCLEX: Physiological Integrity
3. When administering a mental status examination to a patient with delirium, the nurse should a. give the examination when the patient is well-rested. b. reorient the patient as needed during the examination. c. choose a place without distracting environmental stimuli. d. medicate the patient first to reduce anxiety.
Correct Answer: C Rationale: Because overstimulation by environmental factors can distract the patient from the task of answering the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient's delirium. Cognitive Level: Application Text Reference: pp. 1562, 1576-1577 Nursing Process: Implementation NCLEX: Physiological Integrity
A home-health patient with Alzheimer's disease (AD) and mild dementia has a new prescription for donepezil (Aricept). Which nursing action will be most effective in ensuring compliance with the medication? a. Setting the medications up weekly in a medication box b. Calling the patient daily with a reminder to take the medication c. Having the patient's spouse administer the medication d. Posting reminders to take the medications in the patient's house
Correct Answer: C Rationale: Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the Aricept. The other nursing actions will not be as effective in ensuring that the patient takes the medications. Cognitive Level: Application Text Reference: pp. 1563, 1567 Nursing Process: Implementation NCLEX: Physiological Integrity
A long-term care patient with moderate dementia develops increased restlessness and agitation. The nurse's initial action should be to a. administer the PRN dose of lorazepam (Ativan). b. reorient the patient to time and place. c. assess the patient for anything that might be causing discomfort. d. have a nursing assistant stay with the patient to ensure safety.
Correct Answer: C Rationale: Increased motor activity in a patient with dementia is frequently the patient's only way of responding to factors like pain, so the nurse's initial action should be to assess the patient for any precipitating factors. Administration of sedative drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia. Assigning a nursing assistant to stay with the patient may also be necessary, but any physical changes that may be causing the agitation should be addressed first. Cognitive Level: Application Text Reference: p. 1573 Nursing Process: Implementation NCLEX: Physiological Integrity
Coexisting dementia and depression are identified in a patient with Parkinson's disease. The nurse anticipates that the greatest improvement in the patient's condition will occur with administration of a. antipsychotic drugs. b. anticholinergic agents. c. dopaminergic agents and antidepressant drugs. d. selective serotonin reuptake inhibitor (SSRI) agents.
Correct Answer: C Rationale: Parkinson's disease and depression are both potentially reversible conditions, and the patient's symptoms that are caused by these two conditions will improve with appropriate treatment. Anticholinergic agents are likely to worsen the patient's condition because they will block the effect of acetylcholine at the synaptic cleft. There is no indication that the patient needs an antipsychotic agent at this time. A selective serotonin reuptake inhibitor (SSRI) may be effective for the depression, but it does not address the patient's other conditions. Cognitive Level: Application Text Reference: p. 1563 Nursing Process: Planning NCLEX: Physiological Integrity
When assessing a patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility, the nurse learns that the patient has had several episodes of wandering away from home. Which nursing action will the nurse include in the plan of care? a. Ask the patient why the wandering episodes have occurred. b. Reorient the patient to the new living situation several times daily. c. Place the patient in a room close to the nurses' station. d. Have the family bring in familiar items from the patient's home.
Correct Answer: C Rationale: Patients at risk for problems with safety require close supervision. Placing the patient near the nurse's station will allow nursing staff to observe the patient more closely. Use of "why" questions is frustrating for the patient with AD, who are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patient's short-term memory loss, reorientation will not help to prevent wandering behavior. Because the patient had wandering behavior at home, familiar objects will not prevent wandering. Cognitive Level: Application Text Reference: p. 1573 Nursing Process: Planning NCLEX: Safe and Effective Care Environment
A patient with Alzheimer's disease (AD) is hospitalized with a urinary tract infection. The spouse tells the nurse, "I am just exhausted from the constant care and worry. We don't have any children and we can't afford a nursing home. I don't know what to do." The most appropriate nursing diagnosis for the spouse is a. anxiety related to limited financial resources. b. ineffective health maintenance related to stress. c. caregiver role strain related to limited resources for caregiving. d. social isolation related to unrelieved caregiving responsibilities.
Correct Answer: C Rationale: The spouse's statements are most consistent with caregiver role strain. The other diagnoses each address one aspect of the spouse's problem, but caregiver-role strain related to limited resources for caregiving addresses all the information the nurse has about this situation. Cognitive Level: Application Text Reference: pp. 1574-1575 Nursing Process: Diagnosis NCLEX: Psychosocial Integrity
A 62-year-old patient is brought to the clinic by a family member who is concerned about the patient's increasing sleep disturbances and inability to solve common problems. To obtain information about the patient's current mental status, which question should the nurse ask the patient? a. "Where were you were born?" b. "Do have any feelings of sadness?" c. "What day of the week is it today?" d. "How positive is your self-image?"
Correct Answer: C Rationale: This question tests the patient's orientation to time, which is decreased in early Alzheimer's disease (AD) or dementia. Asking the patient about birthplace tests for remote memory, which is intact in the early stages. Questions about the patient's emotions and self-image are helpful in assessing emotional status, but they are not as helpful in assessing mental state. Cognitive Level: Application Text Reference: pp. 1564, 1567 Nursing Process: Assessment NCLEX: Physiological Integrity
A 71-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. variable ability to perform simple tasks. c. difficulty eating and swallowing. d. loss of recent and long-term memory.
Correct Answer: D Rationale: Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient's ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia. Cognitive Level: Application Text Reference: pp. 1562-1563 Nursing Process: Assessment NCLEX: Physiological Integrity
A 72-year-old patient hospitalized with pneumonia is disoriented and confused 2 days after admission. Which assessment information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia? a. The patient is disoriented to place and time but oriented to person. b. The patient has a history of increasing confusion over several years. c. The patient's speech is fragmented and incoherent. d. The patient was oriented and alert when admitted.
Correct Answer: D Rationale: The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia. Cognitive Level: Application Text Reference: p. 1562 Nursing Process: Assessment NCLEX: Physiological Integrity