Chapter 13

Question 1

A patient diagnosed with moderate dementia consistently appears to be distorting the truth resulting in his wife asking, What should I do when he lies to me about unimportant things? Upon what rationale should the nurses response be based?

Answer 1

This isnt lying but rather a way to fill in the memory gaps.

Question 2

The nurse is to perform a complete assessment of a patient in her home, using the Mini-Mental State Examination (MMSE) as one component. When the nurse arrives, the patient is seated at the table with her husband, the TV is on, and several grandchildren are visiting. The patient is quiet, but her hands are gripped tightly, and she is staring at the ceiling. The best action for the nurse to take would be which of the following?

Answer 2

Explain the importance of the testing process and make an appointment for another day when the environment can be better controlled.

Question 3

A patient has been admitted with a diagnosis of hypoactive delirium. Which nursing intervention is supported by this diagnosis?

Answer 3

Scheduling frequent changing of position to prevent skin breakdown

Question 4

Which of the following should the nurse use as a basis for explaining the etiology of Alzheimers disease to the family of a patient with this disease?

Answer 4

It is a primary dementia that is incurable, irreversible, and fatal. It is caused by the presence of a beta-amyloid protein in the neurons resulting in senile plaques.

Question 5

Which outcome is realistic for a patient with stage 1 Alzheimers disease?

Answer 5

The patient will maintain the highest possible functional level to preserve autonomy.

Question 6

The home care nurse is visiting a patient who was discharged to home after a procedure at an ambulatory surgical center. The patient lives alone in a senior retirement community. The nurses assessment documents mild dysphasia. The patient repeatedly asks, Why is there a bandage on my arm? and is not able to state the appropriate day and year. Appropriate planning for the patient should include:

Answer 6

Assessing diet and meal preparation,assessing environment for safety problems, referral to a dementia program

Question 7

A patient diagnosed with Alzheimers disease has a catastrophic reaction during an activity involving simultaneous playing of music and working on a craft project. The patient starts shouting no, no, no and rushes out of the room. The nurse should:

Answer 7

Follow the patient, reassure her, and redirect her to a quieter activity.

Question 8

Which behaviors would indicate that a therapeutic activity program for a patient with Alzheimers disease had been successful?

Answer 8

Increased attention span, verbal expression of remote memory, and positive emotional response

Question 9

A patient has been diagnosed with dementia secondary to cerebral disease. The family members note the patient has not been as sharp as he once was and that he has developed urinary incontinence and a gait disturbance. Which pathophysiology can cause such symptoms?

Answer 9

Normal pressure hydrocephalus

Question 10

When asked about the prognosis for a patient diagnosed with a dementia secondary to normal pressure hydrocephalus the nurse replies:

Answer 10

The symptoms generally remit after a shunt is inserted to drain fluid.

Question 11

Which statement by an adult child concerning the behaviors of their parent supports the diagnosis of Alzheimers disease?

Answer 11

Mom forgot to pay her utility bills last month.

Question 12

The daughter of an older patient with dementia tearfully tells the nurse that she doesnt know whats wrong with her mother, who has begun accusing the family of holding her prisoner. Which nursing diagnosis would be appropriate for this patient?

Answer 12

Disturbed thought processes

Question 13

The daughter of an elderly patient with dementia tearfully tells the nurse that she doesnt know whats wrong with her mother, who has begun accusing the family of stealing her money. The nurse assesses the patients stage of Alzheimers disease as stage:

Answer 13

2

Question 14

An elderly patient was well until 12 hours ago, when she reported to her family that in the middle of the night she awakened to see a man standing at the foot of her bed. There is no evidence that this situation ever happened. This series of events supports which possible diagnosis?

Answer 14

Delirium

Question 15

A patient diagnosed with delirium has become agitated and fearful. Which nursing intervention should the nurse implement to help prevent a catastrophic response?

Answer 15

Place the patient in a safe, nonstimulating environment.

Question 16

A patient has been diagnosed with Alzheimers disease, stage 1. The nurse would expect to help the family plan measures to assist the patient with:

Answer 16

Recent memory loss

Question 17

An elderly patient with dementia has a nursing diagnosis of self-care deficit: bathing, hygiene. She lives alone and the nursing assessment proves reason to believe she has forgotten how to perform hygiene and bathing activities. Which intervention is most appropriate for this patient?

Answer 17

Bathe twice weekly with assistance.

Question 18

Which situation would be most likely to serve as a trigger to a catastrophic reaction in a patient with stage 2 Alzheimers disease?

Answer 18

Being scolded by an aide for spilling a glass of milk

Question 19

Which theory of etiology of Alzheimers disease, suggested by current research, might the nurse use to help a family understand that this disorder is not of psychosocial origin? Alzheimers disease is associated with:

Answer 19

-Amyloid protein deposits in the brain

Question 20

The nurse is administering donepezil (Aricept) to a patient with stage 1 Alzheimers disease. Based on this drugs mechanism of action, the nurse will seek evidence of improvement in the patients:

Answer 20

Ability to remember recent events

Question 21

A patient with dementia is unable to name ordinary objects. Instead, he describes the function of each item (e.g., the thing you cut meat with). The nurse assesses this as:

Answer 21

Agnosia

Question 22

Which intervention has highest priority for a patient with stage 3 Alzheimers disease?

Answer 22

Providing fluids to the patient every hour while awake

Question 23

A patient was admitted to a dementia unit after persistently wandering away from home. Which intervention will best address this patients risk for injury?

Answer 23

Activate alarm system that will alert staff to the patients attempt to open the door.

Question 24

A patient with moderate dementia does not remember her sons name. The son repeatedly questions the mother asking, Do you know my name? The mother invariably becomes agitated. The nurse can most effectively intervene by explaining to the son:

Answer 24

Your mothers dementia is preventing her from retaining information even for short periods of time. She senses your distress and becomes agitated.

Question 25

The wife of a patient with moderate to severe dementia tells the nurse, Im exhausted. He wanders at night instead of sleeping, so I get no rest. Im afraid to leave him during the day, so I have to take him with me wherever I go. The nurse recognizes the need to provide teaching for this caregiver. An appropriate outcome for this teaching would include:

Answer 25

Experiences less stress indicated by improved sleep patterns

Question 26

A teenager is admitted to the ED after being alternately hyperalert and difficult to arouse. The symptoms started within the last few hours, during which time he became disoriented, confused, and delusional. These symptoms support the diagnosis of:

Answer 26

Delirium

Question 27

Which interventions provided by the caregiver will help ensure effective care for the patient diagnosed with dementia? (Select all that apply)
a. Taking the patients blood pressure regularly
b. Being alert to ways the patient might be hurt
c. Keeping the patient on a predictable schedule
d. Assuming responsibility for meeting the patients needs
e. Providing the patient with nonstimulating, private time

Answer 27

B,C,E

Question 28

For which medication will the nurse prepare material for the family of a patient diagnosed with mild to moderate Alzheimers disease? (Select all that apply.)
a. Tacrine (Cognex)
b. Donepezil (Aricept)
c. Haloperidol (Haldol)
d. Rivastigmine (Exelon)
e. Galantamine (Razadyne)

Answer 28

A,B,D,E