Ch. 18

Question 1

An older adult patient takes digoxin and hydrochlorothiazide daily, as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, the patient 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’s disease

Answer 1

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’s disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems.

DIF: Cognitive Level: Application REF: Pages: 273

Question 2

A patient with 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

Answer 2

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.

DIF: Cognitive Level: Comprehension REF: Pages: 274

Question 3

A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, “Someone get the bugs off me.” What is the nurse’s 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.

“Don’t worry, I will have someone stay here and brush off the bugs for you.”

d.

“I don’t see any bugs, but I know you are frightened so I will stay with you.”

Answer 3

ANS: D

When hallucinations are present, the nurse should acknowledge the patient’s feelings and state the nurse’s 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 patient’s 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.

DIF: Cognitive Level: Application REF: Page: 339|Pages: 345-348

Question 4

What is the priority nursing diagnosis for a patient with 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

Answer 4

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 patient’s sensorium is clouded. The other diagnoses may be concerns but are lower priorities.

DIF: Cognitive Level: Application REF: Pages: 336-337

Question 5

What is the priority intervention for a patient 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

Answer 5

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.

DIF: Cognitive Level: Application REF: Pages: 336-338

Question 6

Which environmental adjustment should the nurse make for a patient with delirium and perceptual alterations?

a.

Keep the patient by the nurse’s 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.

Answer 6

ANS: D

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

DIF: Cognitive Level: Application REF: Pages: 336-338

Question 7

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.

Answer 7

ANS: B

A 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.

DIF: Cognitive Level: Comprehension REF: Pages: 274

Question 8

Consider these health problems: Lewy body disease, Pick’s disease, and Korsakoff’s syndrome. Which term unifies these problems?

a.

Intoxication

b.

Dementia

c.

Delirium

d.

Amnesia

Answer 8

ANS: B

The listed health problems are all forms of dementia.

DIF: Cognitive Level: Comprehension REF: Pages: 278

Question 9

A nurse administers medications to four patients with Alzheimer’s 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)

Answer 9

ANS: C

Memantine blocks the NMDA channels and is used in moderate-to-late (severe) 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’s disease.

DIF: Cognitive Level: Application REF: Pages: 290-291

Question 10

An older adult was stopped by police for driving through a red light. When asked for a driver’s 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

Answer 10

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.

DIF: Cognitive Level: Application REF: Pages: 280

Question 11

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’s disease was subsequently diagnosed. Which stage of Alzheimer’s disease is evident?

a.

1 (mild)

b.

2 (moderate)

c.

3 (moderate to severe)

d.

4 (late)

Answer 11

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( advanced apraxia). In stage 4 (late) the ability to talk and walk are eventually lost and stupor evolves.

DIF: Cognitive Level: Analysis REF: Pages: 281

Question 12

Consider these problems: apolipoprotein E (apoE) malfunction, neuritic plaques, neurofibrillary tangles, granulovascular degeneration, and brain atrophy. Which condition corresponds to this group?

a.

Alzheimer’s disease

b.

Acquired immunodeficiency syndrome (AIDS)–related dementia

c.

Wernicke’s encephalopathy

d.

Central anticholinergic syndrome

Answer 12

ANS: A

The problems are all aspects of the pathophysiologic characteristics of Alzheimer’s disease.

DIF: Cognitive Level: Analysis REF: Page: 279

Question 13

A patient with stage 1 Alzheimer’s 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

Answer 13

ANS: B

Memory impairment is present and expected in stage 1 Alzheimer’s disease. Data are not present to suggest the other diagnoses.

DIF: Cognitive Level: Application REF: Pages: 337-344

Question 14

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 patient’s sense of humor by telling jokes or riddles.

Answer 14

ANS: A

Patients with 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 and riddles meaningless.

DIF: Cognitive Level: Application REF: Pages: 346-348

Question 15

Two patients in a residential care facility have dementia. One shouts to the other, “Move along, you’re blocking the road.” The other patient turns, shakes a fist, and shouts, “I know what you’re up to; you’re trying to steal my car.” What is the nurse’s 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.”

Answer 15

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.

DIF: Cognitive Level: Application REF: Pages: 346-348

Question 16

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 patient’s glasses and hearing aids.

d.

Keep the room brightly lit at all times.

Answer 16

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.

DIF: Cognitive Level: Analysis REF: Pages: 346-347

Question 17

A patient with stage 2 Alzheimer’s 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

Answer 17

ANS: D

Agnosia is the inability to recognize familiar objects, parts of one’s body, or one’s 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.

DIF: Cognitive Level: Comprehension REF: Pages: 341-343

Question 18

During morning care, a nursing assistant asks a patient 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 patient’s response?

a.

Sundown syndrome

b.

Confabulation

c.

Perseveration

d.

Delirium

Answer 18

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 patient’s response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario.

DIF: Cognitive Level: Comprehension REF: Pages: 340-342

Question 19

A patient with Alzheimer’s 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.

Answer 19

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.

DIF: Cognitive Level: Application REF: Page: 350

Question 20

Goals and outcomes for an older adult patient with 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

Answer 20

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 with delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for the patient with sensorium problems related to delirium.

DIF: Cognitive Level: Application REF: Pages: 336-337

Question 21

An older adult with moderate-stage dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient’s 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.

Answer 21

ANS: A

The patient with moderate Alzheimer’s 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.

DIF: Cognitive Level: Application REF: Pages: 347-348

Question 22

A patient 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 nurse’s 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.”

Answer 22

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.

DIF: Cognitive Level: Application REF: Page: 341|Pages: 344-345

Question 23

A patient 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.

Answer 23

ANS: B

Reorientation may seem like arguing to a patient with cognitive deficits and increases the patient’s 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.

DIF: Cognitive Level: Application REF: Pages: 346-347

Question 24

What is the priority need for a patient 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

Answer 24

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.

DIF: Cognitive Level: Comprehension REF: Page: 342 TOP: Nursing Process:

Question 25

Which intervention is appropriate to use for patients 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.

Answer 25

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.

DIF: Cognitive Level: Comprehension REF: Page: 339|Page: 345

Question 26

A hospitalized patient with delirium misinterprets reality and a patient with dementia wanders about the home. Which outcome is the priority in both scenarios? Each patient will:

a.

remain safe in the present environment.

b.

participate actively in self-care.

c.

communicate verbally.

d.

acknowledge reality.

Answer 26

ANS: A

Risk for injury is the nurse’s priority concern in both scenarios. Safety maintenance is the desired outcome. The other outcomes are priorities and may not be realistic.

DIF: Cognitive Level: Application REF: Page: 337|Page: 350

Question 27

A patient with Alzheimer’s disease has a dressing and grooming self-care deficit. Designate the appropriate interventions to include in the patient’s plan of care. Select all that apply.

a.

Provide clothing with elastic and hook-and-loop closures.

b.

Label clothing with the patient’s name and the 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.

Answer 27

ANS: A, B, E

Providing clothing with elastic and hook-and-loop closures facilitates patient independence. Labeling clothing with the patient’s 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.

DIF: Cognitive Level: Application REF: Pages: 346-348

Question 28

Which assessment findings would the nurse expect in a patient with delirium? Select all that apply.

a.

Impaired level of consciousness

b.

Disorientation to place and time

c.

Wandering attention

d.

Apathy

e.

Agnosia

Answer 28

ANS: 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.

DIF: Cognitive Level: Application REF: Page: 334

Question 29

A nurse should anticipate that which symptoms of Alzheimer’s 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

Answer 29

ANS: A, B, D

The memories of patients with Alzheimer’s 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.

DIF: Cognitive Level: Application REF: Page: 342