Med-Surg Ch 46: Care of Patients with Cognitive Function Disorders

The caregiver of a patient with dementia tells you, "I just can't do this anumore. I am physically and emotionally exhausted." What is the appropriate intial response? A "Have you considered use of respite care?" B. "I am so sorry that you are experiencing this." C. "Do you have other family members who can help?" D. "Community resources are available that may be helpful."

"I am so sorry that you are experiencing this." *Acknowledging the feelings of the caregiver and the stress they are experiencing is important in supporting them. (1, 3, 4) The other options are all things to explore to help with the burden but validating the caregiver's feelings is most important at this time.

The nurse is planning care for a patient with early AD. Interventions for which patient problems are appropriate for this patient's care plan? (Select all that apply.) A. Reduced cardiac output B. Caregiver stress and fatigue C. Nutritional deficiencies D. Pain E. Airway patency issues

1. Caregiver stress and fatigue 2. Nutritional deficiencies *Patients with AD often forget to eat, so they are at risk for altered nutritional status. Caregivers of AD patients are at extreme risk for fatigue and the effects of chronic stress. Pain, airway patency issues, and reduced cardiac output are not problems associated with early AD.

The nurse is caring for a patient recently diagnosed with AD. The nurse knows this patient's symptoms are caused by which changes in the brain? (Select all that apply.) A. Decreased production of neurotransmitters B. Development of gumma C. Tangled nerve cells D. Neuron loss in frontal and temporal lobes E. Formation of aneurysms

1. Decreased production of neurotransmitters 2. Tangled nerve cells 3. Neuron loss in frontal and temporal lobes *In AD, there is a loss of neurons in the frontal and temporal lobes. The atrophy in these areas accounts for the patient's inability to process and integrate new information and to retrieve memories. Brain biopsies of patients with AD have revealed nerve cells that are tangled and twisted and an abnormal buildup of proteins. Production of neurotransmitters (e.g., acetylcholine, serotonin) is relatively decreased for these patients. Gumma development is associated with syphilis. Aneurysm development is not associated with AD.

The nurse is working on a busy medical-surgical unit. An elderly patient has fallen out of bed twice, despite repeated verbal instructions to call for assistance. What are appropriate interventions to ensure safety? (Select all that apply) A. Encourage family members and friends to stay with the patient B. Obtain an order for an anioxlytic medication C. Keep the patient close to the nurses' station D. Check on the patient frequently to offer nutrition, fluids, pain relief, and toileting E. Place the bed in the lowest position with three side rails up F. Temporarily place restraints and secure knots to the bedrails G. Advise the patient that the hospital is not liable if he refuses to cooperate

1. Encourage family members and friends to stay with the patient 2. Keep the patient close to the nurses' station 3. Check on the patient frequently to offer nutrition, fluids, pain relief, and toileting 4. Place the bed in the lowest position with three side rails up

How should the nurse speak when communicating with a patient with moderate Alzheimer dementia? A. Slowly B. Clearly C. Loudly D. Softly

Clearly *Clarity is essential when communicating with a patient with Alzheimer dementia. placing self directly in front of the patient and using pictures or symbols is helpful

Processes of perception, memorym and judgment A. Cognition B. Dementia C. Delirium

Cognition

You recognize which of the following as symptoms associated with delirium? A. Fading short-term memory, withdrawn behavior, and depression B. Inattention to hygiene, sad countenance, little verbal expression C. Confusion, incoherent speech, sudden onset of symptoms D. Inability to recognize familiar objects, angry outbursts, confusion

Confusion, incoherent speech, sudden onset of symptoms *Patients with delirium have symptoms of confusion and incoherent speech, with the sudden onset of symptoms. (1) Fading short-term memory, withdrawn behavior, and depression are characteristic of Alzheimer disease. (2) Inattention to hygiene, sad countenance, and little verbal expression are common in moderate Alzheimer disease. (4) Inability to recognize familiar objects, angry outbursts, and confusion are particular to moderate to severe Alzheimer disease.

Characterized by slow onset A. Cognition B. Dementia C. Delirium

Dementia

Uses confabulation to cover memory gaps A. Cognition B. Dementia C. Delirium

Dementia

The nurse differentiates vascular dementia from Alzheimer dementia. Which causative factor is responsible for vascular dementia? A. Cerebral atrophy B. Global reduction of cognition C. Hypertension D. Emboli in cerebral vessels

Emboli in cerebral vessels *Vascular dementia occurs from brain tissue becoming hypoxic and necrotic in local areas due to small emoboli. The deficits may be intellectual or loss of sensory function

You identify which patient behavior as indicative of mild Alzheimer disease? A. Has difficulty swallowing during meals B. Needs repeated instructions for simple tasks C. Has difficulty learning new things D. Cannot recognize familiar people

Has difficulty learning new things *Having difficulty learning new things is common in the early stages of Alzheimer disease. (1) Difficulty swallowing is a sign in late Alzheimer disease. (2) Needing repeated instructions for simple tasks is characteristic of moderate Alzheimer disease. (4) Inability to recognize familiar people is a sign of late Alzheimer disease.

A 62-year-old woman is admitted to an assisted-living facility with symptoms of forgetfulness, anger outbursts, wandering, and paranoia. These would suggest which stage of AD? A. Mild B. Severe C. Moderate D. Moderate to severe

Moderate to severe *This patient's symptoms indicate her AD has progressed beyond the early stage. Later signs of disease progression include increasing confusion and inability to recognize self or others.

The nurse is aware that the older adult is at risk for drug-induced delirium. Which age-related change contributes to this risk? A. Slower bowel motility B. Reduced fluid intake C. Overall reduced metabolism D. Sedentary lifestyle

Overall reduced metabolism *Slower renal and liver clearance of drugs allows the drugs to accumulate in the system of the older adult

The health care provider has ordered that the patient be restrained for 24 hours because he is a danger to himself or others. Which task is appropriate to assign to the nursing assistant? A. Selecting the type of restraint B. Checking the circulation in the area distal to the restraint C. Performing 1:1 observation D. Obtaining consent from the patient's family to use restraints

Performing 1:1 observation

The nursing student is assisting the nurse to apply restraints to a patient. Whch action by the student indicates that she understands the procedure? A. She checks the circulation and then applies the restraints B. She ties the knot so that it is not readily visible to the patient, family, or staff C. She states that she will check on the patient every 2-4 hours D. She documents the care that was given while the patient was in restraints

She documents the care that was given while the patient was in restraints

Which caregiver statement regarding donepezil (Aricept) indicates a need for further nursing teaching? A. "I should give this drug with food to minimize gastric distress." B. "Aricept is rarely used because it causes liver problems." C. "I must increase fiber and fluid in my loved one's diet." D. "Providing frequent sips of cool liquids is helpful."

"Aricept is rarely used because it causes liver problems." *Liver functions should be monitored while on Aricept, but the caregiver is probably referring to tacrine, which is rarely prescribed because of hepatotoxicity. (1, 3, 4) The other options are correct. Give Aricept with food, increase fiber and fluid in the diet, and provide frequent sips of cool fluid.

The patient with dementia presents to the clinic for a routine examination. The patient's daughter, who is her full-time caregiver, states to the nurse, "I just don't know how much longer I can go on caring for Mom full time. My kids feel neglected, my marriage is suffering, and I feel so run down." What is the best response by the nurse? A. "You must stay strong for your mother. You are all she has." B. "You should discuss the many medications available for treating and reversing dementia." C. "Your mother's dementia will improve once we correct the cause." D. "As your mother's condition continues to deteriorate, we should discuss alternative care resources."

"As your mother's condition continues to deteriorate, we should discuss alternative care resources." *Dementia is a progressive loss of cognitive function that has no cure or medication that reverses it. Delirium generally improves once the cause is corrected. The nurse should acknowledge that the patient will continue to deteriorate and inform the patient's daughter of available resources to lessen the burden of being the sole caregiver to a family member with dementia. Telling the patient's daughter to be strong is neither therapeutic nor helpful.

An exhausted daughter is the sole caregiver to a patient with moderate Alzheimer disease (AD). She asks the nurse what respite care entails. Which statement indicates that the caregiver understands the nurse's response? A. "My mom would stay in a long-term care facility for a short time while I rest." B. "Home health aides would come to our home and help me with housework." C. "A registered nurse would provide total care for my mom in 3 day interval." D. "I would be connected with a special support group to share stresses and communicate with other caregivers."

"My mom would stay in a long-term care facility for a short time while I rest." *Respite care is placing the patient temporarily in a long-term care facility (usually for no longer than a month) to give the family respite from the responsibility of 24/7 care

Donepezil (Aricept) has been prescribed for a patient with Alzheimer disease (AD). Which statement indicates that the patient and spouse understand teaching about the medication? A. "It is best to take the medication at bedtime." B. "The medication will interact with dark leafy greens." C. "Taking the medication with a citrus beverage should improve absorption." D. "The medication should be take with meals."

"The medication should be take with meals." *Donepezil (Aricept) is used in the management of AD. It has been shown to elevate acetylcholine levels in the brain and will slow the progression of the condition. The medications should be taken with meals to reduce gastrointestinal distress

The nurse is making a home visit to an elderly patient with Alzheimer disease. The patient's wife says, "Jim is more confused compared to usual." What is the best response? A. "It's hard to see someone that you love deteriorate." B. "What kind of changes are you seeing?" C. "When was the last time your husband saw a health care provider? D. "With Alzheimer disease, the symptoms do worsen."

"What kind of changes are you seeing?"

During data collection, the patient's son tells the nurse, "Mom can remember her name, but she doesn't seem to know where she is." Based on this information, which question should the nurse ask first? A. "How does she like to be addressed?" B. "When did you first notice this?" C. "What kind of medications does she take?" D. "When did she last see the health care provider?"

"When did you first notice this?"

You identify which patient behavior as indicative of mild Alzheimer disease? (Select all that apply) A. Encourage verbalization of feelings B. Refer the caregiver to respite care or day care programs C. Remind the caregiver to maintain composure D. Assess for alternative family support and resources E. Reassure the caregiver that everything will be okay F. Encourage consideration of admission to a nursing home G. Tell the caregiver to focus on past happy times with the client

1. Encourage verbalization of feelings 2. Refer the caregiver to respite care or day care programs 3. Assess for alternative family support and resources *Encouraging feelings, giving referrals, and assessing for support are useful to the caregiver. (3) Telling the caregiver to calm down or giving false assurance is not therapeutic or a helpful response. (5) Telling the caregiver that everything will be okay is nontherapeutic, as everything will not be okay. (6) Suggesting admission to a nursing home is unsolicited and premature advice. (7) Telling the caregiver to recall happy times is possibly therapeutic if you have time to have a long discussion, but this suggestion may provoke more guilt and shame if there is no follow-up discussion.

Which criteria must be established to assign a diagnosis of dementia? (Select all that apply) A. Evidence of cognitive deficits B. Evidence of aphasia, apraxia, or agnosia C. Impairment in social function D. Impairments of occupational function E. Neurologic signs and symptoms, such as ataxic gait

1. Evidence of cognitive deficits 2. Evidence of aphasia, apraxia, or agnosia 3. Impairment in social function 4. Impairments of occupational function 5. Neurologic signs and symptoms, such as ataxic gait *Dementia is characterized by several cognitive deficits, memory in particular, and tends to be chronic in nature. It is classified according to etiology (cause or origin of disease). All options are criteria for the diagnosis of dementia

The home health nurse assesses caregivers for a person with a cognitive deficit. Which finding(s) is/are characteristic of exhaustion? (select all that apply) A. Irritability with other family members and the patient B. Report of sleep disturbances C. Anger at patient and self D. Depression E. Fatigue

1. Irritability with other family members and the patient 2. Report of sleep disturbances 3. Anger at patient and self 4. Depression 5. Fatigue *All options are characteristics of exhaustion in caregivers to the cognitively impaired

Alzheimer disease has a greater impact on society than delirium because (select all that apply) A. Memory deficits become progressive B. It often improves with correction of the underlying cause C. It causes mental decline and the need for ongoing, more involved care D. The expense of care for dementia patients is a drain on society and families E. A family member may have to leave the workforce to care for the patient

1. Memory deficits become progressive 2. It causes mental decline and the need for ongoing, more involved care 3. The expense of care for dementia patients is a drain on society and families 4. A family member may have to leave the workforce to care for the patient *With Alzheimer disease, memory deficits are progressive. Mental decline and the need for more and more care increase as the disease progresses. The expense of caring for an Alzheimer patient is a drain on families and society. A family member may have to leave the workforce and stay home to care for a relative with Alzheimer disease. (2) Delirium often improves with the correction of the underlying cause.

Which strategy/strategies best benefit(s) a late-stage Alzheimer patient with global amnesia? (select all that apply) A. Reorientation sessions B. Music therapy C. Reminiscence therapy D. Pet therapy E. Looking at family scrapbooks

1. Music therapy 2. Pet therapy *Global amnesia wipes out all memory. Orientation and family pictures will not be helpful. Activities that stimulate the senses, such as music, stroking an animal, or aroma therapy, can be pleasing

What does the Mini-Mental Status Exam (MMSE) assess? (select all that apply) A. Orientation B, Judgment C. Memory D. Insight E. Ability to follow directions

1. Orientation 2. Memory 3. Ability to follow directions *The Mini-Mental Status Exam (MMSE) is a popular shortened version of the mental status examination that was developed by Folstein and colleagues in 1975. It can be used for patients who have cognitive disorders or thought disorders to assess orientation, memory, and ability to follow commands. It consists of 11 easily scored items and should take about 5 to 10 minutes to administer. The MMSE does not measure insight or judgment

Which interventions will you teach to the caregivers of a patient with Alzheimer disease? (select all that apply) A. Place door locks up high on the doors B. Redirect to another activity when the patient becomes confused C. Keep lights low in the evening to decrease stimulation D. Offer finger foods to increase caloric intake when restless E. Provide lively activity in the late afternoon to prevent sundown syndrome F. Use clothing with Velcro or other easy fasteners

1. Place door locks up high on the doors 2. Redirect to another activity when the patient becomes confused 3. Offer finger foods to increase caloric intake when restless 4. Use clothing with Velcro or other easy fasteners *Placing door locks up high on the doors prevents the patient from opening doors easily. When a patient with dementia becomes obstinate, redirecting to another place or task is helpful. Giving finger foods increases caloric intake when the patient will not settle long enough to eat at a table. Clothing with Velcro fasteners makes it easier for the patient with dementia to dress. (3) Low lights in the evening may cause sundown syndrome. (5) Lively activity in the afternoon can lead to agitation and exhaustion, triggering sundowning.

The nurse is caring for a patient with memory deficits. The patient asks the nurse about foods that may help improve memory. Which food(s) is/are linked to enhance memory? (select all that apply) A. Salmon B. Red meat C. Pork loin D. Leafy green vegetables E. Fruit

1. Salmon 2. Leafy green vegetables 3. Fruit *Studies show that fish and omega3 polyunsaturated fats, fruits and vegetables, curcumin (curry spice), and the traditional Mediterranean diet may lower the risk of cognitive function and/or Alzheimer disease (AD).

Postmortem brain examinations of Alzheimer disease (AD) patients reveal which type of finding(s) (select all that apply) A. Tangled nerve cells B. Abnormal buildup of proteins C. Hemorrhagic areas D. Occluded cerebral vessels E. Reduced white matter

1. Tangled nerve cells 2. Abnormal buildup of proteins *Tangled nerve cells and abnormal buildup of protein in the brain have been found on postmortem brain examination of people who have AD

Which percentage of the population that is 85 years of age and older and has some stage of Alzheimer's disease (AD)? A. 10% B. 20% C. 33% D. 50%

33% *AD is the most common degenerative disease of the brain. Approximately 5.7 million Americans have AD and there is no known cause or cure. AD typically affects people over 65 years of age, but can also strike younger people. The 85 year old and over age group is currently the fastest growing age group in the United States. It is estimated that 1/3 of this age group have AD

The patient with delirium is combative and is putting herself and others at risk. Which nursing intervention should be implemented as an alternative to restraint use? A. Turn the TV up loud to distract the patient. B. Use all four side rails to prevent the patient from getting out of bed. C. Assign a sitter for one-on-one observation. D. Place the patient in a room away from the nurse's station.

Assign a sitter for one-on-one observation. *Nursing interventions that can be used as an alternative to restraints include assigning a sitter for one-on-one observation, reducing noise, and keeping the patient close to the nurse's station. Use of all four side rails should be avoided as it is a strangling hazard and is considered a type of restraint. Three side rails may be used to prevent the patient from rolling out of bed.

The nurse is planning care for patients with cognitive disorders. Which task can be assigned to the nursing assistant? A. Determine which patients need assistance with hygienic care B. Evaluate the patient' responses to reality-orientation therapy C. Assist patients to ambulate in the hall or enclosed courtyard D. Observe patients for changes in mental status during the shift

Assist patients to ambulate in the hall or enclosed courtyard

The home health nurse is counseling a family who will be caring for a relative with moderate-stage Alzheimer disease (AD). Which information is most important to include? A. Construct a consistent routine to provide structured environment B. Try to make each day different to enhace attention span C. Use multiple caregivers to decrease unhealthy attachment and prevent caregiver burnout D. Place bright rugs, flower arrangements, and wall decorations around the room to stimulate sensory perception

Construct a consistent routine to provide structured environment *A consistent routine--eating, resting, medication, hygient--are all beneficial to the demented patient. Different caregivers and distracting environmental objects increase confusion

The nurse is caring for a patient with acquired immune deficiency syndrom (AIDS) dementia complex. Which factor places this patient at particular risk for injury? A. Manic behavior B. Numbness and muscle weakness C. Suicidal ideation D. Difficulty concentrating

Numbness and muscle weakness *Peripheral neuropathy results in numbness and muscle weakness that may contribute to falls and thermal skin injuries

What factors cause elderly patient to be at risk for substance-induced delirium? A. Increased metabolism and reduction in cardiac and liver function B. Decreased metabolism and reduction in cardiac and respiratory function C. Decreased metabolism and reduction in kidney and liver function D. Increased metabolism and reduction in neurologic and immune function

Decreased metabolism and reduction in kidney and liver function

An acute alteration in cognition A. Cognition B. Dementia C. Delirium

Delirium

Experiences an illusion A. Cognition B. Dementia C. Delirium

Delirium

Results from cerebrovascular accident A. Cognition B. Dementia C. Delirium

Delirium

The LPN/LVN reads on a patient's chart that the patient had a sudden onset of confusion with incoherent speech. The patient is likely to be diagnosed with what cognitive disorder? A. Depression B. Delirium C. Alzheimer disease D. Dementia

Delirium *Delirium (acute confusion) is characterized by a change in overall cognition and level of consciousness over a short time. Dementia is characterized by several cognitive deficits, memory in particular, and tends to be more chronic. The difference between the two conditions is that delirium is an acute condition that requires immediate treatment, and is reversible, whereas dementia is a chronic condition that is irreversible. Alzheimer disease is a type of dementia. Depression is not associated with sudden confusion and incoherent speech.

An 85-year-old man is admitted to the hospital with gastroenteritis and dehydration. He receives a dose of meclizine hydrochloride, an anticholinergic, for vomiting. He begins to hallucinate and talk to his wife, who has been dead for 10 years. Which explanation best describes this behavior? A. Dementia related to advanced age B. Delirium related to dehyrdration C. Demential related to early Alzheimer's disease (AD) D. Delirium related to side effect of anticholinergic

Delirium related to side effect of anticholinergic *Anticholinergic drugs can cause sudden confusion in older adults. There is nothing in the history that suggests that the behavior would be related to AD or any other dementia as dementias progress slowly. Dehydration would increase the effect of the anticholinergic

Memory lapses seen in early stages of Alzheimer's disease (AD) are related to pathophysiology of which condition? A. Frontal lobe atrophy B. Overproduction of neurotransmitters C. Pituitary disorders D. Inadequate clearance of metabolic toxins

Frontal lobe atrophy *Loss of neurons in the frontal and temporal lobes results in atrophy and the many signs of AD, memory deficits being one of the earliest

A patient with Alzheimer disease (AD) has been prescribed oral donepezil 10 mg. The nurse should give priority to assessing the patient for which sign of an adverse effect of this drug? A. Skin rashes B. Cardiac dysrhythmias C. Decreased blood pressure D. Gastrointestinal (GI) bleeding

Gastrointestinal (GI) bleeding *Patients receiving donepezil should be monitored for active or occult GI bleeding. Although patients should be assessed for all of these, especially when beginning a new medication, dysrhythmias, rashes, and decreased blood pressure are not associated with donepezil use.

The patient is suffering acute delirium related to a systemic infection. During the evening, the patient appears to be very frightened by the IV tubing. The nurse recognizes that the patient might be experiencing which disturbance? A. Hallucination B. Illusion C. Delusion D. Confabulation

Illusion

The nurse is planning care for a patient with dementia. Which would be an appropriate intervention to include in this patient's care plan? A. Increase verbal and environmental cues. B. Speak loudly and slowly. C. Involve the patient in new activities. D. Restrain the patient for safety.

Increase verbal and environmental cues. *Increasing verbal and environmental cues (e.g., signs indicating bathroom and room locations) can help in orienting patients with dementia. There is no indication that the patient is hard of hearing. New activities would serve to confuse and perhaps agitate a patient with dementia.

The nurse is caring for a patient with who is having difficulty with short-term memory. Which are other signs and symptoms of beginning Alzheimer disease? A. Increased forgetfulness, difficulty learning new things, inability to concentrate B. Unable to speak or ambulate and profound memory loss C. Social withdrawal and decreased ability to perform usual activities of daily living D. Outbursts of anger, hostility, paranoia, and wandering

Increased forgetfulness, difficulty learning new things, inability to concentrate

Which alternative to restraints will you select for an older adult patient on a medical-surgical unit who is confused and trying to get out of bed? A. Raise four side rails of the bed B. Put the patient's mattress on the floor C. Keep the patient in a wheelchair close to the nurse's station D. Use hand mitts and a soft vest with Velcro fasteners

Keep the patient in a wheelchair close to the nurse's station *Putting the patient close to the nurses' station is the least restrictive option. (1, 4) Raising the side rails and using mitts are considered types of restraints. If the nurse opts to use either of these measures, documentation and a health care provider's order are required. (2) Putting the mattress on the floor is not commonly done in a hospital, but it might be considered in other settings, such as the patient's home or a long-term care facility.

The nurse is assisting the patient with middle-stage Alzheimer's disease (AD) with dressing. Which action is most appropriate? A. Select clothes and dress the patient B. Layout clothing and coach the patient to dress self C. Ask the patient what he wants to wear D. Open the closet and tell the patient to choose a shirt

Layout clothing and coach the patient to dress self *Coaching the patient to dress himself helps preserve dignity and function. Selecting clothes and dressing the patient does not allow the patient to actively particpate in any way. Asking the patient what he wants to wear and telling him to choose a short could increase confusion and indecision

The family of an elderly patient who experiences nighttime confusion reports that he has been wandering from his room into the backyard. Which intervention will best decrease this patient's nighttime confusion? A. Assigning a family member to sit with him until he falls asleep B. Allowing the patient to share a room with another family member C. Leaving a night-light on D. Administering a sedative at the hour of sleep

Leaving a night-light on *Keeping the environment well lit is a strategy for decreasing confusion. Leaving a night-light on will help the patient remain oriented to the environment. Sedative effects may actually increase the likelihood of confusion in an elderly patient. A sitter until the onset of sleep will not help in the event the patient gets up and wanders around.

A patient has been diagnosed as having dementia. Which symptom should the LPN/LVN expect? A. Patient tends to have flight of ideas. B. Patient tends to be oriented to time, place, and person. C. Patient's speech tends to be slurred. D. Patient tends to confabulate.

Patient tends to confabulate. *Dementia is characterized by several cognitive deficits, memory in particular, and tends to be chronic. Confabulation is used to fill conversational gaps. Flight of ideas, slurred speech, and orientation to time, place, and person are not dementia symptoms.

The long-term care nurse notices that a resident with chronic dementia is uncharacteristically drowsy and lethargic. What is the appropriate nursing intervention? A. Allow the resident to go to sleep B. Include the resident in a social group for stimulation C. Perform a mental status examination and obtain vital signs D. Call the health care provider to report a change in mental status

Perform a mental status examination and obtain vital signs *The patient should be assessed for additional information about mental status, and vital signs should be obtained and then the health care provider called. (1) Allowing the resident to sleep could be dangerous if they are septic or having neurologic or cardiac problems or fluid and electrolyte imbalances that go undetected. (2) Stimulation with group participation is not appropriate, but the resident should be checked for arousability and response to normal stimuli. (4) The health care provider will need to be notified, but you do not have enough information to make the call until you further assess mental status.

The nurse hears in report that a patient has global amnesia. The nurse will allot extra time for which intervention? A. Talking about family members and their recent visits B. Reminiscing about family holidays and past events C. Reorienting to person, place, and time D. Placing signs and arrows to the bathroom and dining room

Placing signs and arrows to the bathroom and dining room

A 25 year old patient is brought to the emergency department by the police. He is a poor historian but the police tell the nurse that they were called because he was wandering down the middle of the freeway. He appears confused, disheveled, and malnourished. Which problem statement on the care plan would be of highest priority for this patient? A. Altered self-care ability B. Wandering due to disorientation to time and place C. Potential for injury due to impaired decision making D. Altered nutrition

Potential for injury due to impaired decision making

The nurse is caring for a patient in the moderate Alzheimer stage. In planning care, the nurse should anticipate the need for which intervention? A. Repeat the date and time frequently B. Restrain the patient to protect from falls and wandering C. Vary routine and provide unstructured environment D. Allot extra time for grooming and toileting

Repeat the date and time frequently

The nurse is caring for a patient with moderate Alzheimer disease (AD) in a long-term care facility who "sundowns." The nurse understands that which action would be most beneficial for this patient? A. Scheduling social interaction in the morning B. Darkening the bedroom to encourage sleep C. Administering sedatives to enhance sleep initiation D. Scheduling an exercise program after supper

Scheduling social interaction in the morning *Sundowning occurs when a patient is completely oriented during the day but becomes disoriented and confused during the evening and night hours. Planning interactive activities when the residen is not confused is beneficial. Exercise programs at night would add to agitation and confusion. Sedatives also frequently cause confusion. Lights should be left on to assist with reorientation should the resident wake up at night

The CNA approaches the older adult in the long-term care facility and says, "Oh, look! Your pretty dress is icky with food spots! Let's change your clothes, sweetie." The nurse identifies that the CNA is using which type of communication? A. Instruction for personal hygiene B. Encouragement for self-care C. Simplistic "elderspeak" D. Reorientation techniques

Simplistic "elderspeak" *Elderspeak is a way of communicating with older adults, that is, infantile, over-simplistic, over-solicitous, and demeaning. It serves no therapeutic purpose

A recently licensed nurse is orienting to the Alzheimer disease (AD) care unit. The nurse is caring for a patient who is transitioning from oral rivastigmine (Exelon) to the medication patch. Which action indicates an accurate understanding of the medication? A. The nurse instructs the patient to apply the patch 12 h after the last oral medication dosage B. The nurse instructs the patient to replace the patch every 36 h C. The nurse explains that the sites of application will need to be rotated D. The nurse instructs the patient to avoid placing the patch on the trunk region of the body

The nurse explains that the sites of application will need to be rotated *Rivastigmine (Exelon) is used to manage AD by elevating acetylcholine. The medication is available orally and transdermally. The patch should be applied 24 h after the last oral dosage is given. The sites for application of the drug patches should be rotated

The nurse is caring for a patient who has dementia and has been getting up out of bed at night. What action by the nurse is most therapeutic? A. The nurse raises all of the side rails B. The nurse reassigns the patient to a room closer to the nurse's station C. The nure obtains orders from the physician to apply restraints at night D. The nurse places the mattress on the floor

The nurse places the mattress on the floor *The patient poses a significant risk for falls and needs provisions to increase safety. Placing the mattress on the floor decreases the risk of injury from falling from a larger height. Moving the patient closer to the nurse's station does not offer protection or ensure that the patient will be seen or heard. The use of side rails can be considered a restraint and it can present an additional safety hazard. Restraints are to be the last option when caring for patients

In which situation should the nurse document that the patient with AD exhibitied agnosia? A. The patient attempts to comb her hair with a fork B. The patient struggles to express herself verbally C. The patient appears unable to understand written language D. The patient cannot feed herself, despite having adequate motor function

The patient attempts to comb her hair with a fork *Agnosia is the inability to recognize an object and use it as intended. Expressive aphasia is difficulty in expressing oneself. Alexia is the inability to recognize the written language. Apraxia is the inability to do an activity despite having the motor function to accomplish it

The patient with Alzheimer's disease (AD) has been on donepezil (Aricept) for several weeks. In which situation would the nurse suspect an overdose? A. The patient hungrily eats meals and often searches for snacks between meals B. The nurse assesses a radial pulse rate of 92 beats per minute C. The patient's blood pressure is elevated after periods of exertion D. The patient fails to grasp a glass tightly enough to prevent dropping it

The patient fails to grasp a glass tightly enough to prevent dropping it *Inability to grasp the glass indicates muscle weakness, a cardinal indicator of overdose of Aricept. Other overdose signs are hypotension, nausea, and vomitingm and bradycardia. Appetite changes are not consistent with the use of this medication

The nurse is caring for a patient with Alzheimer disease (AD) who wakes up moaning and frightened in the middle of the night. She begs that her husband's coffin be removed from her room. How should the nurse respond? A. Turn light on and say, "There is no coffin here. This is the dresser." B. Leave the light off and shine a flashlight on the dresser and say, "See! No coffin!" C. Turn the light on, assist patient to the bathroom, and say, "This is your dresser." D. Leave the light off and say, "You are in your room."

Turn the light on, assist patient to the bathroom, and say, "This is your dresser." *Turning the light on helps reorient the patient. Distraction of going to the bathroom ad identifying the dresser assist with reorientation after a frightening illusion. The other options would lead to greater confusion

An elderly patient with mild dementia has demonstrated ability to feed himself, perform toileting independently, and dress himself; however, he frequently says, "You do it for me." What should the nurse do to encourage independence? A. Instruct him to try first, and then come back later to see what he has accomplished B. Verbally coach him through the task and observe his performance C. Point out to him that he needs to be independent for as long as possible D. Ask him why he frequently does not want to do things for himself

Verbally coach him through the task and observe his performance

You observe that a patient with mild dementia has difficulty buttoning a shirt. Which nursing intervention is appropriate? A. Verbally coach the patient using simple direction B. Leave the patient alone and give extra time and privacy C. Have the nursing assistant help the patient get dressed D. Give the patient a shirt with Velcro fasteners

Verbally coach the patient using simple direction *The patient needs repetitive coaching to perform the task. This may be more time consuming than simply putting the shirt on them but allowing as much independence in tasks as possible increases self-esteem. (2) If the patient is left alone, it is unlikely that they will dress themself. (3) Having the nursing assistant dress the patient is marginally better than doing it yourself, but both you and the nursing assistant should try to coach the patient to do things for themself. (4) Velcro fasteners help if fine motor skills are the issue.

The nurse notes that newly admitted patient with Alzheimer disease (AD) has significant anomia. Which intervention is most appropriate for this problem? A. Frequently reorient the patient to his room location B. Remind the patient about the names and uses for particular items C. Assist the patient with all meals D. Wait patiently for the patient to find the word he wants

Wait patiently for the patient to find the word he wants *Anomia is the inability to recall a word. Waiting for the patient to remember the word or be able to substitute another is more supportive than supplying the word for him

A patient is experiencing acute delirium with confusion related to medication side effects. What is the best environmental intervention to use with this patient? A. Turn on a favorite program to provide a familiar distraction B. Ask several family members to come and talk about everyday topics C. Put the patient close to the nurses' station with the door open D. Assign a nursing student to observe 1-to-1 in a quiet room

assign a nursing student to observe 1-to-1 in a quiet room

The patient is prescribed memantine (Namenda). Common side effects to instruct the patient about are: A. insomnia, nervousness, and anxiety B. weight gain, increased thirst, and gastrointestinal upset C. blurred vision, dizziness, and hypotension D. gastrointestinal bleeding, anorexia, and nausea

gastrointestinal bleeding, anorexia, and nausea