MED/SURG2: Chapter 59

Benzodiazepines are indicated in the treatment of cases of delirium that have which cause?

Alcohol withdrawal

The nurse recognizes that which intervention may be beneficial to a patient in the early stages of Alzheimer's disease (AD)?

Memory aids such as calendars

A patient with Alzheimer's disease presents with increased vocalization and agitation. What do these symptoms indicate?

Pain

Which professionals have a high risk of developing Alzheimer's disease or another type of dementia? Select all that apply.

-Football players -Race car drivers -Military members

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 -Use pureed foods and thickened liquids -Remind the patient to chew and swallow the food

Which is a key characteristic of delirium?

Occurs abruptly

Which is the most common cause of dementia?

Alzheimer's disease

The nurse is reviewing the elements of a mini-cog study. What assessment factors are included in this study?

Ask patients to draw and read the hands of a clock and point out a specific time.

A patient with disorganized, distorted thinking and slow or accelerated incoherent speech is demonstrating which cognitive problem?

Delirium

The nurse is caring for a hospitalized patient. Which observation does the nurse identify as a possible beginning sign of delirium?

Awake at 3 AM

The nurse is providing care to a pediatric patient with dementia. Which is a ventricular disorder that could be the cause of the dementia in this patient?

Hydrocephalus

A patient is diagnosed with Lewy body dementia. The nurse anticipates that which medication will be prescribed?

Levodopa

What does the letter "M" represent in the mnemonic, "DELIRIUM," to remember causes of delirium?

Metabolic disorders

The nurse is providing care to several patients on a medical-surgical unit. Which patient's dementia is caused by a neurodegenerative disorder?

The patient with Alzheimer's disease

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?

CT scan of the brain

The nurse is reviewing assessment data from the psychiatric patient who is admitted. Which findings indicate the patient is suffering from depression?

Can last at least two weeks, but can be several months to years

A patient seeks medical attention because of cognitive impairment. The patient is diagnosed with Alzheimer's disease. Which finding forms the basis for the diagnosis?

Cognitive impairment with etiologies other than Alzheimer's disease ruled out.

A patient with progressive dementia begins to exhibit involuntary muscle movements and weakness. Which health problem does the nurse suspect?

Creutzfeldt-Jakob disease

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

What is the leading risk factor for delirium?

Dementia

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?

Diabetes greatly increases a person's chances of developing AD

For which patient should the nurse prioritize an assessment for depression?

A patient in the early stages of Alzheimer's disease

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.

-Distraction -Redirection -Reassurance

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 -Do not ask the patient challenging "why" questions

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

The nurse is providing care to a patient who is diagnosed with Alzheimer's disease (AD). Which medication is appropriate for the nurse to administer when the patient is experiencing agitation and physical aggression?

Haloperidol

The nurse is conducting a teaching session on health strategies to decrease the risk for developing Alzheimer's disease (AD). Which statement made by a participant indicates the need for further education?

"Drinking a few glasses of wine each day has been shown to decrease the incidence of AD."

The nurse is assessing an adult patient during a scheduled health maintenance visit. The patient states, "I have become so forgetful. I am worried that I am developing Alzheimer's disease like my parent did." Which assessment question will help to determine if the patient has memory loss related to Alzheimer's disease (AD)?

"Have you ever forgotten what an item is used for?"

The nurse provides teaching about prescribed medications to a patient who is diagnosed with Alzheimer's disease (AD). Which statement made by the patient indicates the need for further teaching?

"I will take trazodone if I become agitated."

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 -A clear pattern of inheritance within the family -An early onset of the disease (before 60 years of age)

The nurse is caring for a patient with a neurologic disorder. Which factors should the nurse consider risk factors for developing dementia? Select all that apply.

-Aging -Family history -Diabetes mellitus

While completing a health history the nurse identifies that a patient is at risk for developing dementia. What data does the nurse use to make this clinical determination? Select all that apply.

-BMI 32.7 -A 10-year history of type 2 diabetes mellitus -Takes two antihypertensive medications and maintains a blood pressure 150/88 mm Hg

A nurse is caring for a patient with Alzheimer's disease in an adult day care facility. What are the nursing management goals that will help this patient? Select all that apply.

-Have dignity maintained -Maintain functional ability -Have personal care needs met

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

The nurse is providing care to a patient with Alzheimer's disease (AD) who is hospitalized for an appendectomy. Which actions are appropriate when providing care to the patient? Select all that apply.

-Providing reassurance to the patient -Assessing closely for safety concerns -Orienting frequently to place and time

Which are early symptoms associated with Alzheimer's disease (AD) that the nurse will include in patient and family teaching sessions? Select all that apply.

-Wearing a sweater on a hot day -Having rapid mood swings for no apparent reason -Experiencing unexplained confusion in the workplace

A patient is being evaluated for cognitive impairment. The nurse prepares to administer the Mini-Cog test to the patient as part of the assessment process. Which score range indicates a positive screen for dementia?

0 to 2

The nurse is caring for a patient with delirium. The patient becomes severely agitated. Which risk is the nurse's priority concern for this patient?

Falls

Which nursing intervention is most appropriate when caring for patients with dementia?

Give simple directions, focusing on one thing at a time

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 glucose levels cause microangiopathy, which damages blood vessels of the brain

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?

Use a calendar and family pictures as memory aids

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

A patient diagnosed with Alzheimer's disease is prescribed donepezil. What is the purpose of this medication?

Possibly slows the rate of cognitive decline.

A patient who is demonstrating signs of delirium is scheduled for a CT scan of the brain. What does the prescription for the diagnostic test suggest to the nurse?

Potential head injury is causing the symptoms

The nurse is using the mini-cog test to assess a patient for the presence of dementia and possibly Alzheimer's disease (AD). Which statement is appropriate for the nurse to include when administering the test to the patient?

"Draw the hands of the clock to read 11:10."

Which statement by the spouse of a patient with Alzheimer's disease (AD) demonstrates an accurate understanding of the patient's medication regimen?

"I'm really hoping my spouse's medications will slow down the mental losses."

A patient is diagnosed with vascular dementia. What is appropriate for the nurse to include when explaining the disorder to the patient's family?

"It occurs after a single or multiple strokes."

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.

-Ensuring a well-lit stairwell -Tacking down carpet edges -Installing grab rails by the toilet

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 -Gently touch the patient's arm when talking -Remind that patient that he or she is in the hospital

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 -Anesthesia for pacemaker insertion surgery

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.

-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

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?

Adult day care

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)?

An 80-year-old African American female

Which patient may face the greatest risk of developing delirium?

An older patient who takes multiple medications to treat various health problems

The nurse is caring for a patient with variant Creutzfeldt-Jakob disease. What should the nurse suspect as the source of infection?

Beef

The nurse is providing care to an adult patient who is diagnosed with mild cognitive impairment (MCI). The nurse anticipates that which treatment will be prescribed?

Continued monitoring

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?

Health care decisions, including advanced directives, should be made while the patient is able to participate in the decision making.

An older patient who takes haloperidol for delirium is exhibiting extrapyramidal effects. What action should the nurse take?

Discuss the use of a benzodiazepine with the primary health care provider

The nurse is providing care to an adult patient who is diagnosed with moderate Alzheimer's disease (AD). Which assessment data indicate that the patient has progressed from moderate to severe AD?

Having difficulty eating and swallowing

Which medication would the nurse expect to be prescribed for a patient with delirium related to alcohol withdrawal?

Lorazepam

The nurse determines that a patient with delirium will benefit from pharmacologic intervention. The nurse made this conclusion based on what action performed by the patient?

Pulled out hemodialysis catheters during a dialysis session

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

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?

"Your children should consider genetic testing to determine their risk for AD."

Which statement is true regarding the pathophysiology of Alzheimer's disease (AD)?

In patients diagnosed with AD, more plaques appear in certain parts of the brain

A patient with a history of Alzheimer's disease is seen in the health care provider's office. Which symptom is consistent with the mild stage of the disease?

Patient has difficulty in learning new skills

Which medication helps improve memory and cognition in patients with Alzheimer's disease?

Rivastigmine

A patient who is demonstrating delirium is being admitted to the hospital. What is the nursing priority of care?

Safety

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?

Serum potassium

An older adult patient with a history of a cardiovascular disease is undergoing treatment in a long-term care facility. Which disease is the patient most at risk of developing?

Vascular dementia

The nurse is preparing a plan of care to reduce an elderly patient's risk of developing delirium. What is appropriate for the nurse to include on the plan? Select all that apply.

-Provide for uninterrupted sleep during the night -Assess for pain with every vital signs assessment -Ensure that eyeglasses and hearing aids are within reach

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?

Symmetrical atrophy of the temporal lobes

A nurse is teaching a group of caregivers about how to detect the early warning signs of Alzheimer's disease. What are the warning signs that the nurse should include in the teaching? Select all that apply.

-Problems with language -Disorientation to time and place -Memory loss that affects job skills

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.

-Hypertension -Hypercholesterolemia

A group of patients who have a high risk of developing Alzheimer's disease attend adult day care. What interventions would help promote mental health? Select all that apply.

-Learn new skills -Exercise regularly -Solve crossword puzzles

A nurse is assessing an older adult patient with memory loss. What symptoms are found in the patient with Alzheimer's disease, separate from normal forgetfulness? Select all that apply.

-Loses sense of time -Forgets what an item is used for -Little awareness of cognitive problems

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 -Difficulty with normal conversation

The nurse is caring for an older adult patient. For what symptoms of dementia should the nurse be observant? Select all that apply.

-Memory loss -Cognitive dysfunction -Abrupt changes in behavior

The nurse is working in a health care facility with patients with neurologic disease. The nurse understands that some neurologic diseases may be curable if detected early. Which disease, if detected early, is curable?

Normal pressure hydrocephalus

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?

Perform a physical assessment, including monitoring vital signs and signs of pain

A patient develops dementia, becomes incontinent of urine, and has difficulty walking over several months. A neurologic examination and diagnostic testing reveal that the patient has normal pressure hydrocephalus. How is this condition treated?

Surgery with insertion of a ventricular-peritoneal shunt

The nurse identifies that a patient with delirium is at risk for injury. What interventions should be added to the patient's plan of care to address the safety concerns? Select all that apply.

-Place a calendar within view. -Reorient the patient to person, place, and time as necessary

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.

-Previous health history -Serum electrolyte values -Medications routinely taken

The nurse visits an older adult patient at home. The patient's spouse expresses concern that the patient is developing Alzheimer's disease. What behavioral pattern in an older adult may indicate normal forgetfulness related to aging? Select all that apply.

-Occasionally forgets to run an errand -May forget an event from the distant past -Sometimes misplaces keys, eyeglasses, or other items