Ch. 25 Care for Individuals for Neurocognitive Disorders

When differentiating the characteristics of depression, delirium, and dementia, the nurse recognized which of the following as an indicator of delirium? a. Sudden onset b. Recent loss c. Insidious d. Life change

ANS: A Delirium can occur suddenly. Recent loss or life changes can precipitate depression. Dementia can be insidious and slow and occur over the course of several years.

4. Which assessment parameter should the nurse use to differentiate between delirium and depression in an older adult? a. Orientation b. Activity c. Course over the morning hours d. Psychomotor activity

ANS: A Qualities about the patient's orientation are a good method for the nurse to use for distinguishing between delirium and depression; in delirium, orientation is usually impaired, and in depression, orientation is normal. Activity can vary throughout the day and is not a good indicator. Delirium tends to be worse at night, and depression tends to be worse in the morning. The nurse avoids using qualities about the patient's psychomotor activities to distinguish between delirium and depression in an older adult; psychomotor activities in both disorders are highly variable and make distinctions difficult.

At 10 PM, an older male resident attempts to climb over the bedrails. Which intervention should the nurse implement first? a. Talk to the resident about his behavior. b. Call the physician, and ask for a sedative. c. Apply a vest restraint on the resident. d. Get a companion to keep him in the bed.

ANS: A The resident is expressing a need that the nurse can potentially determine with gentle questioning. Pharmacologic intervention can be necessary but should not replace careful evaluation and management of the underlying cause. Simply restraining the patient will not address the underlying problem, and the imposition of restraints can trigger delirium. Applying a restraint is the last resort, and the nurse must consider the problems that accompany the application of restraints before doing so. Placing a companion in the room can be an effective method of keeping the resident safe if the companion can determine and meet the resident's needs.

. An older woman has a wound infection 5 days after a below-the-knee amputation brought about by diabetes mellitus. Which of the following is the nurse's priority intervention to prevent cognitive dysfunction and postoperative complications in this older adult? a. Remove invasive devices as soon as possible. b. Minimize the administration of opioid analgesics. c. Allow for self-care and independent activities. d. Administer short-acting benzodiazepines as needed.

ANS: A To help prevent cognitive dysfunction, postoperative complications, and an increased risk of morbidity and mortality, the nurse recognizes that the risk factors this older adult has for delirium include stressors, infection, and surgery; therefore, to prevent cognitive decline and additional postoperative complications, the nurse promptly removes invasive devices such as intravenous infusions, urinary catheters, and wound drains. Removing these devices not only reduces the risk of infection, thromboembolic events, blood loss, injury, and fluid imbalance, but they also serve to promote mobility, promote a sense of control for the patient, and reduce the types of situations that can frighten the patient or that the patient can misinterpret. Poor pain management can contribute to delirium in older patients. A patient with multiple stressors and risk factors for delirium needs additional nursing care and attention to provide a calming, caring therapeutic environment. The nurse must assess the patient's functional status before allowing self-care and independent activities. In addition, this older adult is likely to need extensive physical therapy to maintain mobility. Benzodiazepines are a poor pharmacologic choice for older adults for sedation or sleep; they can contribute to delirium, are highly addictive, and can cause rebound insomnia if suddenly withdrawn.

Which intervention to manage wandering in clients in a long-term care facility should be implemented? (Select all that apply.) a. Camouflaging doorways b. Close observation to identify the person's individual patterns c. Engaging the person in social interactions d. Using physical restraints to prevent wandering to maintain safety e. Providing enclosed pathways for walking

ANS: A, B, C, E Restraints are not an effective intervention for wandering. Although they might physically prevent the person from wandering, restraints have many potential negative consequences and patient harm associated with their use. Environmental modifications such as camouflaging doorways and providing enclosed pathways, close observation to identify the person's individual patterns, and engaging the person in social interactions are all interventions that are effective strategies to manage wandering

. The nurse working in a long-term care facility completes her morning assessment on a new postoperative patient and notes a change in cognitive status from the previous day? The nurse recognizes which of the following as a precipitating factor for delirium? (Select all that apply.) a. Major medical treatment b. Poor sleep habits c. Admission to long-term care d. Pharmacological agents

ANS: A, C, D Major medical treatment, admission to long-term care, and pharmacologic agents are all precipitating factors for delirium. Changes in surroundings often precipitate delirium. The development of delirium is a result of complex interactions among multiple causes. Delirium can result from the interaction of predisposing factors—vulnerability on the part of the individual as a result of predisposing conditions, such as cognitive impairment, severe illness, and sensory impairment; delirium can also result from precipitating factors and insults—medications, procedures, restraints, and iatrogenic events. Although a single factor (e.g., infection) can trigger an episode of delirium, several coexisting factors are also likely to be present. A highly vulnerable older individual requires a lesser amount of precipitating factors to develop delirium. Poor sleep habits is not a contributing factor in of itself.

An older client diagnosed with dementia resides with his daughter. When the home care nurse visits, the daughter tearfully tells the nurse that her father scratched her hand and cursed at her when she was attempting to feed him. She states, "I don't know why he hates me and wants to hurt me. I try so hard to take good care of him. I love him." How will the nurse respond to the client's daughter? a. "Let's think about what you may have done to anger your father." b. "Let's try to figure out what your father was trying to say with his behavior." c. "Scratching is usually a sign of untreated pain. Do you think your father is in pain?" d. "Maybe you should consider having a home health provide your father's physical care."

ANS: B Dementia often interferes with the person's communication and the ability to understand and express thoughts and feelings. The focus needs to be on what the person is attempting to communicate through behavior. Behavioral manifestations are not necessarily signs of anger in persons with dementia. Although behavioral manifestations frequently are seen in persons with untreated pain, this is not always true. The issue here is not necessarily the individual who is providing the care but perhaps the care activity itself. It is appropriate for the daughter to provide care for her father.

An older woman is recovering from a bowel resection in the intensive care unit (ICU) but remains intubated and on a mechanical ventilator. Which of the following should the nurse implement to help prevent delirium in this woman? a. Assess cognition with the Mini-Mental State Examination, 2nd edition (MMSE-2). b. Provide uninterrupted periods of rest and sleep. c. Maintain adequate sedation and pain management. d. Cover the patient's eyes with protective ophthalmic ointment.

ANS: B Providing uninterrupted periods of rest and sleep is a challenge for the nurse in the ICU. Because of the nature of the patients' illnesses, nurses administer medications and treatments and perform invasive procedures on a 24-hour basis, leaving patients little time for rest. Many patients become delirious in the ICU because the noise, activity, brightness, and disturbance tend to persist around the clock, which contribute to delirium. Patients lose their sources for maintaining orientation and stability; that is, bright lighting at all times, as well as unfamiliar and abrupt increases in noise, can lead to a disruption in the circadian rhythm. In addition, patients in the ICU are more likely to receive multiple medications, and medications that are potentially harmful can aggravate the patient's cognitive difficulties. Because this patient is intubated and on mechanical ventilation, the nurse cannot apply the MMSE-2; the patient is unable to perform adequately. Besides, assessing for dementia is not a prophylactic measure. Sedation and pain management, although often needed in the ICU, can contribute to delirium. Covering the eyes of a patient in the ICU with ointment can be necessary to prevent corneal damage; however, it is likely to contribute to delirium because the patient will be unable to see clearly

. Which of the following should the nurse use to assess a nonverbal older adult for delirium? a. Cranial nerves (CNs) XI and XII b. Confusion Assessment Method (CAM) c. MMSE-2 d. Controlled Word Association Test

ANS: B The CAM is a tool for measuring delirium in patients who are intubated or nonverbal. Assessing the accessory (CN XI) and hypoglossal (CN XII) CNs provides clues about the patient's ability to swallow. The nurse uses the Controlled Word Association Test to assess for a neurologic cause of an older adult's cognitive dysfunction. This tool is an index of frontal lobe functioning and provides an assessment of executive function, including the patient's frontal lobe functioning and his or her ability to refrain from distraction and perseveration. The MMSE-2 is a valid and reliable tool to assess cognitive function; however, it is unable to pinpoint discrete areas of neurologic dysfunction.

Which information will the nurse manager include when discussing the major differentiation between delirium and dementia with novice nurses? (Select all that apply.) a. The delirious client learns to make up answers to hide their confusion. b. Delirium requires increased monitoring at night. c. The client diagnosed with dementia generally looks frightened. d. Dementia results in a steady decline in cognitive abilities. e. Delirium is characterized by fluctuations in alertness.

ANS: B, D, E The correct options accurately describe the conditions of delirium and dementia. The other statements are false; it is the client experiencing dementia who will over the course of the illness learn to confabulate to cover up their memory losses, and the delirious client is more likely to show fear through facial expressions.

A definitive diagnosis of Alzheimer's disease (AD) can be made by detecting or using which one of the following methods? TestBankWorld.org a. Clinical observation of dementia b. Inability to speak with relevance c. Development of neurofibrillary tangles d. Computed tomography (CT) scan

ANS: C Confirming the development of neurofibrillary tangles is the only accurate method for diagnosing AD. Patients with AD can be observed for dementia and delirium, but these indicators are nonspecific for the disease. The inability to speak with relevance is a feature of dementia; if other causes of dementia are ruled out, then it may be dementia of the Alzheimer type. A CT scan is the most useful means for diagnosing a stroke.

The nurse recognizes which of the following displays may indicate hyperactive delirium? a. Lethargy b. Withdrawn behavior c. Nonpurposeful repetitive movements d. Decreased psychoactive activity

ANS: C Patients with hyperactive delirium often wander and have nonpurposeful repetitive movements. Lethargy and withdrawn behavior are both indicative of hypoactive delirium. Patients with hyperactive delirium have increased psychoactive activity, not decreased.

An older woman with dementia exhibits new behaviors including crying and repeatedly verbalizing the same phrase; furthermore, the behavior has increased over 2 days. Which intervention should the nurse implement in response to this behavior? a. Tell her you will remember what she says if she stops crying. b. Attribute these findings to a deterioration in cognitive function. c. Check the medication administration record for missed doses. d. Present probing questions to the patient about her behavior

ANS: C TestBankWorld.org New behaviors with increasing frequency warrant further investigation by the nurse to ensure that effective nursing care can be planned and implemented. Crying and repeated verbalizations from a patient with dementia can indicate anxiety, but the cognitive disorder makes anxiety difficult to detect. In addition to checking for missed doses, the nurse checks the medication record for medications that are likely to cause anxiety, such as beta-adrenergic agonists, which are used to reverse bronchoconstriction. The nurse should also check for risk factors for anxiety and perform a comprehensive assessment to identify potential causes. The nurse should avoid making a veiled threat to the patient. Giving the patient the incentive to stop crying can be suitable. However, the incentive should never be attention; the duty of the nurse is to pay close attention to the patient. The new behavior can be deteriorating cognitive function, but the nurse must first assess the patient further before making that determination. One aspect of the assessment is to question the patient. Depending on the stage of dementia, the patient can be an unreliable source of information about herself.

Which of the following approaches to hygienic care is beneficial for a patient with dementia? a. Schedule the patient's full shower at 7 AM, three mornings every week. b. Have a team give the bath with each member washing a different body area. c. Wash the perineal region first to remove potentially infectious material. d. Explain each step as you go and keep the patient covered as much as possible while bathing.

ANS: D A person with dementia can interpret undressing for bathing as an assault. It should be performed in a way that minimizes the intrusive and exposing aspects and maintains trust between the person and only one caregiver. From the point of view of the well-being of the patient, bathing is rarely an emergency that it must be performed at a time when the patient is not receptive. Stimulation should be kept simple and focused, and alarming the patient should be avoided. The most sensitive and intimate areas should be washed last, after trust has been established between the patient and the nurse, which may have to be done anew at every encounter. From an infection-control standpoint, washing occurs from clean to dirty areas.

Which of the following statements is true about cognitive impairments in older adults? a. Loss or interruption of sleep can lead to delirium. b. Confusion is a normal and unavoidable consequence of aging. c. Older patients who are agitated often have a lower cognitive status than those who are quietly sitting. d. The Mini-Mental State Exam-2 (MMSE-2) should be administered on admission to detect delirium.

ANS: D The MMSE-2 or a similar instrument should be administered to a patient at admission to ascertain the patient's baseline cognitive status. The loss or interruption of sleep, in of itself, does not often lead to delirium. It can potentiate delirium in the presence of other factors. Confusion or delirium is not a normal consequence of aging but an indicator of a potentially underlying problem. The hypoactive subtype of delirium can be associated with a worse prognosis than with the hyperactive subtype; it is easily overlooked.