MH(Nuerocognitive Disorders, chapter 60 MS)

When a client demonstrates symptoms associated with delirium, the nurse institutes care focused on the prevention of which result? 1.Hallucinations 2.Disorientation 3.Impaired memory 4.Neurological damage

4. Delirium is always secondary to an underlying condition; therefore it is temporary, transient, and may last from hours to days once the underlying cause is treated. If the cause is not treated, permanent damage to neurons can result. The remaining options are typically associated with delirium.

A client with dementia is unable to recognize ordinary objects such as a pen or notebook. The nurse recognizes this symptom as: A) Agnosia B) Amnesia C) Apraxia D) Aphasia

A Feedback: Agnosia is the inability to recognize familiar objects. Amnesia is failure to remember past events. Apraxia is an impairment in the ability to execute motor functions despite intact motor abilities. Aphasia is a deterioration of language function.

A person who is the primary caregiver for a mother with Alzheimer disease says, "Sometimes I hate my mother for living this long and Dad for dying and not caring for her.". Which response is most therapeutic? a. "What do you do to cope with these negative feelings?" b. "It's fairly common for a caregiver to feel such negative emotions.". c. "Have you ever felt angry enough to be abusive toward your mother?" d. "Please consider discussing these feelings with other members of your family.".

A The answer that invites the patient to share feelings and perceptions (thus facilitating emotions) is the most therapeutic communication. The correct response uses exploring, a therapeutic communication technique. The remaining options are either premature or make unsubstantiated assumptions.

Which assessment findings would the nurse expect in a patient experiencing delirium? Select all that apply. a. Impaired level of consciousness b. Disorientation to place and time c. Wandering attention d. Apathy e. Agnosia

A,B,C Disorientation to place and time is an expected finding. Orientation to person (self) usually remains intact. Attention span is short, and difficulty focusing or shifting attention as directed is often noted. Patients with delirium commonly experience illusions and hallucinations. Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is associated with depression

When administering a mental status examination to a patient, the nurse suspects depression when the patient responds with a.I dont know. b.Is that the right answer? c.Wait, let me think about that. d.Who are those people over there?

ANS: A Answers such as I dont 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.

A client has Alzheimer dementia. Her husband of 50 years is no longer able to safely care for her at home, so he has placed her in an extended care facility. When her husband visits her, she smiles and talks about their many travels around the world. Intrigued, a nurse asks the client's husband to describe their travels. He laughs and says, "We've never been out of the United States." The nurse instructs the husband that the client's tales are an example of: A) Aphasia. B) Confabulation. C) Delirium. D) Apraxia.

B

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.

In assessing a client who has suddenly become confused and agitated, what is the important initial step in evaluating the basis for the diminishing cognitive abilities? a. Rule out any reversible condition that may be causing the symptoms. b. Identify the specific type of dementia that the client is exhibiting. c. Perform genetic testing to diagnose or rule out Alzheimer's disease. d. Perform a comprehensive battery of neuropsychological tests.

A In evaluating older clients for diminishing cognitive abilities the nurse must rule out any reversible conditions that may be causing the symptoms. Determining outcomes will be highly dependent on whether and how much the impairment can be arrested, slowed, or reversed. Doing so will maximize the quality of life for the affected individual.

Which intervention is best associated with minimizing the effects of dementia-induced aphasia? 1. Increasing reliance on nonverbal communication methods 2. Speaking in a slow, deliberate manner 3. Delivering information in short, simple phrases 4. Engaging in reminiscing therapy by focusing on familiar topics

1. Aphasia presents with the client having difficulty in expressing oneself verbally, understanding speech, and with reading and writing. When aphasia starts to hinder communication, nonverbal communication becomes important. Cognitive dysfunction results in issues with processing information that are assisted by presenting information in a slow, deliberate manner using simple, short phrases. Reminiscing therapy is appropriate when addressing memory loss.

A patient with mild dementia has a new prescription for donepezil (Aricept). Which nursing action will be most effective in ensuring compliance with the medication? a.Having the patients spouse administer the medication b.Setting the medications up weekly in a medication box c.Calling the patient daily with a reminder to take the medication d.Posting reminders to take the medications in the patients house

ANS: A 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 drug. The other nursing actions will not be as effective in ensuring that the patient takes the medications.

To protect a patient from injury during an episode of delirium, the most appropriate action by the nurse is to a.secure the patient in bed using a soft chest restraint. b.ask the health care provider about ordering an antipsychotic drug. c.instruct family members to remain with the patient and prevent injury. d.assign a nursing assistant to stay with the patient and offer frequent reorientation.

ANS: D 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.

Which environmental adjustment should the nurse make for a patient experiencing delirium with perceptual alterations? a. Keep the patient by the nurses desk while the patient is awake. Provide rest periods in a room with a television on. b. Light the room brightly, day and night. Awaken the patient hourly to assess mental status. c. Maintain soft lighting day and night. Keep a radio on low volume continuously. d. Provide a well-lit room without glare or shadows. Limit noise and stimulation.

ANS: D A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient experiencing cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations.

The nurse is developing interventions to promote socialization in a client with moderate dementia. Which of the following provides a safe and secure environment for the client? A) A card game with other clients B) An activity with the nurse C) Decorating a bulletin board with the group D) Morning stretch group with music

B Feedback: The client has to interact only with the nurse, who will behave in a predictable way and will focus on the client's needs, without undue or unexpected disruptions. Group activities do not provide a safe and secure environment as does an activity done with the nurse.

A client with moderate Alzheimer's disease is living with her grown daughter. Which of the following statements by the daughter indicates the need for intervention by the nurse? A) "It's distressing when my mother forgets my name." B) "I wish my sister would come to visit more often." C) "Mother won't let anyone else do anything for her." D) "Taking care of my mother is a big responsibility."

C Feedback: When the caregiver feels as though no one else can provide care, the risk for role strain is markedly increased. Answers A, B, and D are normal responses to a family member of a client with moderate Alzheimer's disease.

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

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.

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.

Which nursing diagnosis should be the priority for the nurse who is caring for a client with dementia who is disoriented, ataxic, and wanders? A) Disturbed thought processes B) Self-care deficit C) Risk for trauma D) Risk for other-directed violence

c

An older client has been diagnosed with infection-induced delirium. Which statement by the nurse to the client's family best demonstrates an understanding of the disorder while addressing the family's concerns? 1. "Delirium isn't permanent when treated appropriately. The prescribed medication should eliminate the infection causing the symptoms." 2. "The symptoms of delirium can be very difficult to watch in a loved one. Try not to worry since the condition is not permanent." 3. "Infections commonly cause delirium in older clients. You'll see improvement in just a few days." 4. "The symptoms will come and go during the next few days. It's a common condition."

1. Delirium can be a result of an infection especially among older adult clients. The condition is reversible when appropriately treated. A common concern is whether the symptoms are permanent since ineffective treatment of the underlying cause can lead to dementia if not reversed. Providing an explanation that identifies cause, treatment, and positive outcomes best demonstrates an understanding of the disorder while meeting the needs of the family. None of the remaining options provide all the required information.

What assessment history data indicates that a client is at increased risk for developing Alzheimer's disease (AD)? 1. Currently being treated for anorexia nervosa 2. Has sustained two serious concussions 3. Re-occurring bladder infections 4. Current hypotension

2. There is little known about the actual causes of AD. There are a number of risk factors, including advancing age, head trauma, obesity, diabetes, unmanaged hypertension, low socioeconomic status and educational levels, and the presence of apolipoprotein E4 (APOE E4 allele), among others. Infection is a risk factor for delirium. There is no known connection between AD and anorexia nervosa.

Which nursing intervention best meets the unique needs of the client diagnosed with delirium? 1. Keeping environment well lighted 2. Reassuring the client during periods of fearfulness 3. Frequently assessing level of consciousness and orientation 4. Concisely explaining why an intervention is going to occur

3. Because levels of consciousness can change throughout the day, the patient needs to be checked for orientation (time, place, and person) frequently during different times of the day. While appropriate the remaining options address needs of any client experiencing either dementia or delirium.

A nurse case manager meets with a family who is caring for the wife's elderly father who is diagnosed with advanced dementia. The wife remarks, "It's getting harder and harder to keep him safe without tying him up. I get so frustrated when he doesn't even know who I am and fights me." Which response would BEST use commendation to encourage and reinforce the wife's strengths? a. "You have provided excellent care to him every day for several years; let's see how we can help you take care of yourself so he continues to be well cared for." b. "It's your turn to be taken care of; you deserve a medal for dealing with the situation this long." c. "It will be difficult to find someone who can take care of him as well as you have, but let's see what we can come up with." d. "I don't know how you have put up with those behaviors as long as you have; I would have given up long before this."

A The most therapeutic response by the case manager would be to acknowledge the wife's efforts and offer to explore with the family strategies so that the elder will continue to be cared for effectively. In addition, the case manager acknowledges the caregiver role strain that is occurring and the need to explore strategies for the caregiver to obtain respite and address her own needs. The nurse is demonstrating empathy and effective listening when she is able to address the concerns of the family.

When assessing a patient with Alzheimers 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.Place the patient in a room close to the nurses station. b.Ask the patient why the wandering episodes have occurred. c.Have the family bring in familiar items from the patients home. d.Reorient the patient to the new living situation several times daily.

ANS: A Patients at risk for problems with safety require close supervision. Placing the patient near the nurses station will allow nursing staff to observe the patient more closely. The use of why questions is frustrating for patients with AD because they are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patients short-term memory loss, reorientation will not help prevent wandering behavior. Because the patient had wandering behavior at home, familiar objects will not prevent wandering.

An older adult takes digoxin and hydrochlorothiazide daily, as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, this adult developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of: a. delirium. b. dementia. c. amnestic syndrome. d. Alzheimer disease.

ANS: A Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems.

A patient has progressive memory deficit associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Promote the use of the patients sense of humor by telling jokes.

ANS: A Patients with a cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the patient is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the patient. Patients with cognitive deficits may lose their sense of humor and find jokes meaningless.

A hospitalized patient experiencing delirium misinterprets reality, and a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? Each patient will: a. remain safe in the environment. b. participate actively in self-care. c. communicate verbally. d. acknowledge reality.

ANS: A Risk for injury is the nurses priority concern in both scenarios. Safety maintenance is the desired outcome. The other outcomes may not be realistic.

Goals and outcomes for an older adult patient experiencing delirium caused by fever and dehydration will focus on: a. returning to premorbid levels of function. b. identifying stressors negatively affecting self. c. demonstrating motor responses to noxious stimuli. d. exerting control over responses to perceptual distortions.

ANS: A The desired overall goal is that the patient with delirium will return to the level of functioning held before the development of delirium. Demonstrating motor responses to noxious stimuli is an appropriate indicator for a patient whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a patient experiencing delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for the patient with sensorium problems related to delirium.

Consider these problems: apolipoprotein E (apoE) malfunction, neuritic plaques, neurofibrillary tangles, granulovascular degeneration, and brain atrophy. Which condition corresponds to this group? a. Alzheimer disease b. Wernicke encephalopathy c. Central anticholinergic syndrome d. Acquired immunodeficiency syndrome (AIDS)related dementia

ANS: A The problems are all aspects of the pathophysiologic characteristics of Alzheimer disease.

An older adult diagnosed with moderate-stage dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patients family? a. Label the bathroom door. b. Take the older adult to the bathroom hourly. c. Place the older adult in disposable adult diapers. d. Make sure the older adult does not eat nonfood items.

ANS: A patient with moderate Alzheimer disease has memory loss that begins to interfere with activities. This patient may be able to use environmental cues such as labels on doors to compensate for memory loss. Regular toileting may be helpful, but a 2-hour schedule is often more reasonable. Placing the patient in disposable diapers is more appropriate as a later stage intervention. Making sure the patient does not eat nonfood items will be more relevant when the patient demonstrates hyperorality.

A nurse should anticipate that which symptoms of Alzheimer disease will become apparent as the disease progresses from moderate to severe to late stage? Select all that apply. a. Agraphia b. Hyperorality c. Fine motor tremors d. Hypermetamorphosis e. Improvement of memory

ANS: A, B, D The memories of patients with Alzheimer disease continue to deteriorate. These patients demonstrate the inability to read or write (agraphia), the need to put everything into the mouth (hyperorality), and the need to touch everything (hypermetamorphosis). Fine motor tremors are associated with alcohol withdrawal delirium, not dementia. Memory does not improve.

A patient diagnosed with Alzheimer disease has a dressing and grooming self-care deficit. Designate the appropriate interventions to include in the patients plan of care. Select all that apply. a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patients name and name of the item. c. Administer antianxiety medication before bathing and dressing. d. Provide necessary items, and direct the patient to proceed independently. e. If the patient resists, use distraction and then try again after a short interval.

ANS: A, B, E Providing clothing with elastic and hook-and-loop closures facilitates patient independence. Labeling clothing with the patients name and the name of the item maintains patient identity and dignity (and provides information if the patient has agnosia). When a patient resists, using distraction and trying again after a short interval are appropriate because patient moods are often labile; the patient may be willing to cooperate during a later opportunity. Providing the necessary items for grooming and directing the patient to proceed independently are inappropriate. Staff members are prepared to coach by giving step-by-step directions for each task as it occurs. Administering anxiolytic medication before bathing and dressing is inappropriate. This measure would result in unnecessary overmedication.

Which action will the nurse in the outpatient clinic include in the plan of care for a patient with mild cognitive impairment (MCI)? a.Suggest a move into an assisted living facility. b.Schedule the patient for more frequent appointments. c.Ask family members to supervise the patients daily activities. d.Discuss the preventive use of acetylcholinesterase medications.

ANS: B Ongoing monitoring is recommended for patients with MCI. MCI does not interfere with activities of daily living, acetylcholinesterase drugs are not used for MCI, and an assisted living facility is not indicated for MCI.

Which intervention will the nurse include in the plan of care for a patient who has late-stage Alzheimers disease (AD)? a.Encourage the patient to discuss events from the past. b.Maintain a consistent daily routine for the patients care. c.Reorient the patient to the date and time every 2 to 3 hours. d.Provide the patient with current newspapers and magazines.

ANS: B 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, and the patient will not be able to read.

When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse include? a.Provide complete personal hygiene care for the patient. b.Remind the patient frequently about being in the hospital. c.Reposition the patient frequently to avoid skin breakdown. d.Place suction at the bedside to decrease the risk for aspiration.

ANS: B 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.

During morning care, a nursing assistant asks a patient diagnosed with dementia, How was your night? The patient replies, It was lovely. I went out to dinner and a movie with my friend. Which term applies to the patients response? a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium

ANS: B Confabulation is the making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The patients response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario.

An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police took the person home, the spouse reported frequent wandering into neighbors homes. Alzheimer disease was subsequently diagnosed. Which stage of Alzheimer disease is evident? a. 1 (mild) b. 2 (moderate) c. 3 (moderate to severe) d. 4 (late)

ANS: B In stage 2 (moderate), deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. Hygiene may begin to deteriorate. Stage 3 (moderate to severe) finds the individual unable to identify familiar objects or people and needing direction for the simplest of tasks. In stage 4 (late), the ability to talk and walk are eventually lost, and stupor evolves.

A patient diagnosed with stage 1 Alzheimer disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time? a. Risk for injury b. Impaired memory c. Self-care deficit d. Caregiver role strain

ANS: B Memory impairment is present and expected in stage 1 Alzheimer disease. Patients diagnosed with early Alzheimer disease often have difficulty remembering names, so socialization is minimized. Data are not present to support the other diagnoses.

A patient diagnosed with Alzheimer disease wanders at night. Which action should the nurse recommend for a family to use in the home to enhance safety? a. Place throw rugs on tile or wooden floors. b. Place locks at the tops of doors. c. Encourage daytime napping. d. Obtain a bed with side rails.

ANS: B Placing door locks at the top of the door makes it more difficult for the patient with dementia to unlock the door because the ability to look up and reach upward is diminished. All throw rugs should be removed to prevent falls. The patient will try to climb over side rails, increasing the risk for injury and falls. Day napping should be discouraged with the hope that the patient will sleep during the night.

A patient diagnosed with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Strategically place large clocks and calendars.

ANS: B Reorientation may seem like arguing to a patient experiencing cognitive deficits and increases the patients anxiety. Validating, talking with the patient about familiar, meaningful things, and reminiscing give meaning to existence both for the patient and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and strategically placing large clocks and calendars are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable; patients with dementia sometimes become more agitated with reorientation.

Consider these health problems: Lewy body disease, Pick disease, and Korsakoff syndrome. Which term unifies these problems? a. Intoxication b. Dementia c. Delirium d. Amnesia

ANS: B The listed health problems are all forms of dementia.

. What is the priority nursing diagnosis for a patient experiencing fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Bathing/hygiene self-care deficit, related to altered cerebral function, as evidenced by confusion and inability to perform personal hygiene tasks b. Risk for injury, related to altered cerebral function, misperception of the environment, and unsteady gait c. Disturbed thought processes, related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear, related to sensory perceptual alterations, as evidenced by hiding from imagined ferocious dogs

ANS: B The physical safety of the patient is the highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful; when the patient exercises poor judgment; and when the patients sensorium is clouded. The other diagnoses may be concerns but are lower priorities.

Which description best applies to a hallucination? A patient: a. looks at shadows on a wall and says, I see scary faces. b. states, I feel bugs crawling on my legs and biting me. c. becomes anxious when the nurse leaves his or her bedside. d. tries to hit the nurse when vital signs are taken.

ANS: B hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The incorrect options are examples of behaviors that sometimes occur during delirium and are related to fluctuating levels of awareness and misinterpreted stimuli.

When teaching the children of a patient who is being evaluated for Alzheimers 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.new drugs have been shown to reverse AD dramatically in some patients. c.a diagnosis of AD can be made only when other causes of dementia have been ruled out. d.the presence of brain atrophy detected by MRI confirms the diagnosis of AD in patients with dementia.

ANS: C 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 and does not confirm an AD diagnosis.

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.Provide hourly orientation to time of day. b.Move the patient to a quieter room at night. c.Keep blinds open during the daytime hours. d.Have the patient take a brief mid-morning nap.

ANS: C 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.

An older adult was stopped by police for driving through a red light. When asked for a drivers license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia c. Agnosia d. Memory impairment

ANS: C Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. No evidence of memory loss is revealed in this scenario.

What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Avoidance of physical contact b. High level of sensory stimulation c. Careful observation and supervision d. Application of wrist and ankle restraints

ANS: C Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient remains safe and free from injury while hospitalized. Physical contact during care cannot be avoided. Restraint is a last resort, and sensory stimulation should be reduced.

An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful? a. Place large clocks and calendars on the wall. b. Place personally meaningful objects in view. c. Use the patients glasses and hearing aids. d. Keep the room brightly lit at all times.

ANS: C Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations.

What is the priority need for a patient diagnosed with late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Maintenance of nutrition and hydration d. Prevention of the patient from wandering

ANS: C In late-stage dementia, the patient often seems to have forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the patient is to live. The patient is incapable of self-care, ambulation, or verbal communication.

A long-term care patient with moderate dementia develops increased restlessness and agitation. The nurses initial action should be to a.reorient the patient to time, place, and person. b.administer the PRN dose of lorazepam (Ativan). c.assess for factors that might be causing discomfort. d.have a nursing assistant stay with the patient to ensure safety

ANS: C Increased motor activity in a patient with dementia is frequently the patients only way of responding to factors like pain, so the nurses 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 also may be necessary, but any physical changes that may be causing the agitation should be addressed first.

When used for treatment of patients diagnosed with Alzheimer disease, which medication would be expected to antagonize N-methyl-D-aspartate (NMDA) channels rather than cholinesterase? a. donepezil (Aricept) b. rivastigmine (Exelon) c. memantine (Namenda) d. galantamine (Razadyne)

ANS: C Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterase inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimer disease.

Two patients in a residential care facility are diagnosed with dementia. One shouts to the other, Move along, youre blocking the road. The other patient turns, shakes a fist, and shouts, I know what youre up to; youre trying to steal my car. What is the nurses best action? a. Administer one dose of an antipsychotic medication to both patients. b. Reinforce reality. Say to the patients, Walk along in the hall. This is not a traffic intersection. c. Separate and distract the patients. Take one to the day room and the other to an activities area. d. Step between the two patients and say, Please quiet down. We do not allow violence here.

ANS: C Separating and distracting prevents escalation from verbal to physical acting out. Neither patient loses self-esteem during this intervention. Medication is probably not necessary. Stepping between two angry, threatening patients is an unsafe action, and trying to reinforce reality during an angry outburst will probably not be successful when the patients are cognitively impaired.

Which intervention is appropriate to use for patients diagnosed with either delirium or dementia? a. Speak in a loud, firm voice. b. Touch the patient before speaking. c. Reintroduce the health care worker at each contact. d. When the patient becomes aggressive, use physical restraint instead of medication.

ANS: C Short-term memory is often impaired in patients with delirium and dementia. Reorientation to staff is often necessary with each contact to minimize misperceptions, reduce anxiety level, and secure cooperation. Loud voices may be frightening or sound angry. Speaking before touching prevents the patient from feeling threatened. Physical restraint is not appropriate; the least restrictive measure should be used.

A patient experiencing fluctuating levels of awareness, confusion, and disturbed orientation shouts, Bugs are crawling on my legs! Get them off! Which problem is the patient experiencing? a. Aphasia b. Dystonia c. Tactile hallucinations d. Mnemonic disturbance

ANS: C The patient feels bugs crawling on both legs, although no sensory stimulus is actually present. This description coincides with the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium.

A 62-year-old patient is brought to the clinic by a family member who is concerned about the patients inability to solve common problems. To obtain information about the patients current mental status, which question should the nurse ask the patient? a.Where were you were born? b.Do you have any feelings of sadness? c.What did you have for breakfast? d.How positive is your self-image?

ANS: C This question tests the patients recent memory, which is decreased early in Alzheimers disease (AD) or dementia. Asking the patient about birthplace tests for remote memory, which is intact in the early stages. Questions about the patients emotions and self-image are helpful in assessing emotional status, but they are not as helpful in assessing mental state.

When administering a mental status examination to a patient with delirium, the nurse should a.medicate the patient first to reduce any anxiety. b.give the examination when the patient is well-rested. c.reorient the patient as needed during the examination. d.choose a place without distracting environmental stimuli.

ANS: D Because overstimulation by environmental factors can distract the patient from the task of answering the nurses 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 patients delirium.

A 72-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.difficulty eating and swallowing. c.variable ability to perform simple tasks. d.loss of both recent and long-term memory.

ANS: D 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 patients ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia.

To determine whether a new patients confusion is caused by dementia or delirium, which action should the nurse take? a.Assess the patient using the Mini-Mental Status Exam. b.Obtain a list of the medications that the patient usually takes. c.determined whether there is positive family history of dementia. d.Use the Confusion Assessment Method tool to assess the patient.

ANS: D The Confusion Assessment Method tool has been extensively tested in assessing delirium. The other actions will be helpful in determining cognitive function or risk factors for dementia or delirium, but they will not be useful in differentiating between dementia and delirium.

A patient diagnosed with stage 2 Alzheimer disease calls the police saying, An intruder is in my home. Police investigate and discover the patient misinterpreted a reflection in the mirror as an intruder. This phenomenon can be assessed as: a. hyperorality. b. aphasia. c. apraxia. d. agnosia.

ANS: D Agnosia is the inability to recognize familiar objects, parts of ones body, or ones own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movements, such as being unable to dress.

A patient diagnosed with dementia no longer recognizes family members. The family asks how long it will be before their family member recognizes them when they visit. What is the nurses best reply? a. Your family member will never again be able to identify you. b. I think that is a question the health care provider should answer. c. One never knows. Consciousness fluctuates in persons with dementia. d. It is disappointing when someone you love no longer recognizes you.

ANS: D Therapeutic communication techniques can assist family members to come to terms with the losses and irreversibility dementia imposes on both the loved one and themselves. Two of the incorrect responses close communication. The nurse should take the opportunity to foster communication. Consciousness does not fluctuate in patients with dementia.

A patient experiencing fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, Someone get these bugs off me. What is the nurses best response? a. There are no bugs on your legs. Your imagination is playing tricks on you. b. Try to relax. The crawling sensation will go away sooner if you can relax. c. Dont worry. I will have someone stay here and brush off the bugs for you. d. I dont see any bugs, but I know you are frightened so I will stay with you.

ANS: D When hallucinations are present, the nurse should acknowledge the patients feelings and state the nurses perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patients perception without offering help does not emotionally support the patient. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions.

A family asks why their father is attending activity groups at the long-term care facility. The son states, "My father worked hard all of his life. He just needs some rest at this point." Which is the appropriate nursing reply? A. "I'm glad we discussed this. We'll excuse him from the activity groups." B. "The groups benefit your father by providing social interaction, sensory stimulation, and reality orientation." C. "The groups are optional. Only clients at high functioning levels would benefit." D. "If your father doesn't go to these activity groups, he will be at high risk for developing dementia."

B The most appropriate nursing reply is to educate the family on the purpose of activity groups, which is to provide social interaction, sensory stimulation, and reality orientation. Groups can also serve to increase self-esteem and reduce depression.

The nurse can distinguish delirium from dementia by knowing which of the following? A) Delirium has an acute onset and is progressive in course. B) Delirium has a gradual onset and can be resolved. C) Dementia has a gradual onset and is progressive in course. D) Dementia has an acute onset and can be resolved.

C Feedback: Delirium has a sudden onset and the underlying cause is treatable; by contrast, dementia has a gradual onset and is progressive rather than treatable.

The grown daughter of a woman with Alzheimer's disease reports to the nurse that she is trying to keep her mother's condition from worsening by asking her questions whenever they are together. The nurse recognizes that this activity is likely to do which of the following? A) Decrease environmental misinterpretation B) Improve memory retention C) Increase frustration D) Slow the progress of the disease

C Feedback: Alzheimer's disease is progressive; clients do not learn new information, and they become frustrated when asked to perform tasks they are not capable of doing.

The nurse is assessing a client with early signs of dementia. The nurse asks the client what he ate for breakfast that morning. The purpose of this question is to determine which of the following? A) Orientation B) Food preferences C) Recent memory D) Remote memory

C Feedback: The initial sign of dementia is memory loss for recent events that exceeds normal forgetfulness. Asking what the client ate for breakfast is not determining orientation, food preferences, or remote memory.

An older adult newly diagnosed with depression says, "Yesterday was such a busy day and with everything I had to remember I couldn't recall where I had parked my car. Am I getting Alzheimer disease?" An appropriate response from the nurse would be: a. "Would you like me to have your health care provider discuss your concerns with you?" b. "I do this all the time myself. It will get better after you've taken your antidepressant medication for a while.". c. "When people are very busy or depressed, it's not unusual for them to be forgetful. Nevertheless, let's talk about your concerns.". d. "It sounds as if you may have some memory deficit for recent events. When did you first begin to notice your problem with forgetfulness?"

C People who are busy and people who have depression can experience short-term memory loss since both states are more likely to result in a shorter attention span and lack of mental focus.

The essential characteristics of dementia include multiple cognitive deficits, including impairment of memory and at least one other. Which of the following other criteria must be met for the diagnosis of dementia? a. severe loss of sleep b. poor judgment c. disturbance and decline in everyday functioning d. agitation and aggression toward caregivers

C The impairment must be significant enough to cause a disturbance of everyday functioning and a decline from previously higher level functioning for a diagnosis of dementia to be made. In addition to impairment of memory, either aphasia, apraxia, agnosia, or a disturbance in executive functioning must be present as well.

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.

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.

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.

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.

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: 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.

The nurse is caring for a client with Alzheimer's disease. The nurse observes that the client's pacing and mumbling to himself increase at mealtime and shift change. Which of the following interventions should the nurse implement first? A) Administer an antianxiety drug such as lorazepam (Ativan) at these times. B) Explain the unit routine and the reasons for increased activity to the client. C) Keep unit activity to a minimum. D) Move the client to a quieter area during these times.

D Feedback: The nurse must alter the environment because the client will not learn new coping skills for frustrating or overly stimulating situations. Administering an antianxiety agent or explaining the routine of the unit and reasons for increased activity to the client may be done, but they are not the best initial intervention. The unit activity does not need to be kept at a minimum.

A client diagnosed with neurocognitive disorder due to Alzheimer's disease can no longer ambulate, does not recognize family members, and communicates with agitated behaviors and incoherent verbalizations. The nurse recognizes these symptoms as indicative of which stage of the illness? A. Confabulation stage B. Early stage C. Middle stage D. Late stage

D The nurse should recognize that this client is in the late stage of Alzheimer's disease. The late stage is characterized by a severe cognitive decline.