Chapter 17 Mentation and Sensory Motor Complications of Acute Illness Flashcards
1) A patient is demonstrating confusion and difficulty focusing. Which assessment findings would the nurse evaluate as supporting a diagnosis of delirium rather than dementia?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
1. The confusion cleared when the patient was rehydrated.
2. The patient does not recognize her daughter.
3. The patient’s daughter reports that her mother has been becoming increasingly confused over the last 6 months.
4. The patient’s mentation was clear yesterday.
5. The patient does not recognize that she is confused
Answer: 1, 4
Explanation: 1. Delirium is an acute state of mental status change that can be triggered by metabolic conditions such as dehydration. Since the confusion cleared with rehydration, the diagnosis of delirium is supported.
2) A patient being treated with haloperidol for symptoms of delirium has a blood pressure reading of 190/110 mm Hg. Which nursing action is priority?
1. Encourage the patient to drink at least 240 mL of fluids.
2. Contact the prescriber about an increase in the haloperidol dosage.
3. Place the patient on seizure precautions.
4. Hold the haloperidol dose and collaborate with the prescriber.
Answer: 4
Explanation: 1. There is no indication that fluid intake will treat this drug reaction.
2. The patient may be experiencing an adverse drug reaction, so increasing the dose is not indicated.
3. Seizure is a possibility, but is not the primary nursing action.
4. One nursing implication for a patient prescribed haloperidol is to monitor for neuroleptic malignant syndrome, especially in those patients who take lithium or who have hypertension. One indicator of neuroleptic malignant syndrome is instability of blood pressure. The nurse should contact the prescriber and discuss discontinuing the drug.
3) A ventilator-dependent patient has been in a coma for several weeks. Which finding would the nurse evaluate as indicating there is possibility of reversing this coma state?
1. Testing indicates that the patient has brain function.
2. The patient has clear breath sounds with no indications of pneumonia.
3. The patient cardiac rhythm strip reveals normal sinus rhythm.
4. The patient’s urinary output has remained adequate throughout the coma state.
Answer: 1
Explanation: 1. Coma is characterized by the absence of arousal and awareness and may be reversible if brain function continues. Since the patient has been assessed to have brain function, the patient is not brain dead and it is possible that the coma can be reversed.
2. While the complication of pneumonia would be a compounding factor in reversing coma, the absence of pneumonia does not indicate potential for reversal.
3. Presence of cardiac dysrhythmias is a compounding factor in reversing coma, but absence of dysrhythmia does not indicate potential for reversal.
4. Development of renal failure would compound the reversal of the coma state, but presence of normal kidney function does not indicate potential for reversal.
4) A patient was recently discharged from the hospital following a protracted illness that included mechanical ventilation and treatment for sepsis. At his first postdischarge physician appointment, the patient reports “just not feeling like myself” and being “tired all the time.” How would the nurse respond to this report?
1. “You should feel a lot better now that you are out of the hospital.”
2. “I am not surprised because you were very sick.”
3. “It may take several weeks before you get your strength back.”
4. “You have to follow your discharge instructions and take all your medications correctly.”
Answer: 3
Explanation: 1. Critical illness polyneuropathy is common in seriously ill patients. They do not automatically “feel better” after discharge.
2. “I am not surprised” is not a helpful response.
3. Patients who have had long hospitalizations, have been on mechanical ventilation, and who have had sepsis may have developed critical illness polyneuropathy. Over half of patients make a complete recovery, but it may take weeks or months.
4. Asking about following discharge instructions and taking medications is placing blame on the patient for a condition that is likely out of his control.
5) A patient in the intensive care unit has pulled out her peripheral intravenous line twice and continually picks at her abdominal dressing. How should the nurse describe this behavior?
1. As hyperactive dementia
2. As hyperactive delirium
3. As hypoactive delirium
4. As mixed dementia
Answer: 2
Explanation: 1. There is no indication that this patient has dementia.
2. Hyperactive delirium, also referred to as ICU psychosis, is characterized by agitation, restlessness, and “picking” at monitoring, feeding, or intravenous devices.
3. Hypoactive delirium is characterized by lethargy rather than agitation, withdrawal, flat affect, apathy, and decreased responsiveness.
4. There is no indication that this patient suffers from dementia.
6) An older adult patient in the intensive care unit recovering from an abdominal aortic aneurysm repair begins to show signs of delirium. The nurse realizes that which situation is the most likely cause of this change in mentation?
1. The patient’s intravenous line is infiltrated.
2. The patient has been NPO (nothing by mouth) for an extended period of time.
3. The patient’s oxygen saturation has dropped from 96% to 90%.
4. The patient was started on a patient-controlled analgesia (PCA) pump with morphine.
Answer: 4
Explanation: 1. Infiltration of an intravenous line would not be a likely cause of change in mentation.
2. NPO status, as long as the patient is receiving fluids and nutrition parenterally, is not a likely etiology for this change in mentation.
3. This amount of change in oxygen saturation is not the likely cause of the patient’s mental status change since the level is still within normal limits.
4. Medications are the most prevalent modifiable risk factor for delirium in acute or critically ill elderly patients. Opioid narcotics, such as morphine and fentanyl, are linked to the development of delirium. This is what the nurse should suspect as the cause of the patient’s new onset of decreasing responsiveness.
7) From the use of the confusion assessment method (CAM)-ICU assessment tool, a patient is found to have hypoactive delirium. Which nursing intervention is indicated?
1. Use the prn order for morphine to control the patient’s pain.
2. Use wrist restraints to maintain monitoring devices and lines.
3. Restrict visitors to times when the patient’s mentation is clearest.
4. Reorient the patient to the environment as needed.
Answer: 4
Explanation: 1. Morphine has been linked to an increase in delirium and should be avoided if it is suspected as being the cause for the patient’s delirium.
2. Delirium can be worsened by the use of physical restraints.
3. The presence of family and significant others often helps to reassure and reorient the patient. Visitation should be encouraged even during times of decreased mentation.
4. One of the causative factors of delirium is change in environment. The nurse should reorient the patient as needed in a calm and reassuring manner
8) A patient diagnosed with delirium has a history of adverse reaction to haloperidol. Which medication would the nurse anticipate using instead of haloperidol?
1. Phenytoin
2. Risperidone
3. Morphine
4. Amiodarone
Answer: 2
Explanation: 1. Phenytoin is used to manage seizures.
2. For patients unable to tolerate haloperidol for delirium, risperidone is an alternative.
3. Morphine is prescribed to control pain and may cause a worsening of delirium.
4. Amiodarone is a cardiac medication.
9) A patient is being maintained under neuromuscular blockade-induced paralysis. Analgesia is also being provided. The level of paralysis is being measured by the train-of-four method. The nurse evaluates that the patient’s sedation is adequate when which response occurs?
1. The patient moans when medications for analgesia are reduced.
2. The patient withdraws from a series of four applications of cold water into the ear.
3. The patient’s thumb twitches twice when an electrical impulse is applied.
4. The patient responds to at least one of four applications of digital pressure over pressure points.
Answer: 3
Explanation: 1. Train-of-four does not measure response to analgesic medication withdrawal.
2. Train-of-four does not include cold water application into the ear.
3. Train-of-four testing is a series of low-frequency electrical impulses to the ulnar nerve at the forearm. A positive response is achieving one or two thumb twitches out of the four electrical impulses applied.
4. Train-of-four does not require application of digital pressure
10) An older adult patient admitted to the intensive care unit with acute respiratory injury from aspiration is at risk for developing critical illness polyneuropathy (CIP). What information does the nurse provide to this client’s family?
1. Prevention of this condition is important because very few persons experience complete recovery.
2. Tight control of blood glucose may help prevent this condition.
3. The major concern with this illness is impairment of the patient’s ability to breath.
4. If this condition develops intensive antibiotic therapy will be necessary.
Answer: 2
Explanation: 1. Complete recovery is expected in about half of cases.
2. It is believed that tight glucose control with intensive insulin therapy can reduce the incidence of critical illness polyneuropathy by 44%.
3. Autonomic function, and therefore spontaneous respiration, is preserved in this disorder.
4. There is no known treatment for this disorder.
11) Upon assessment of a patient in the intensive care unit, the nurse suspects critical illness polyneuropathy is developing. Which finding would support this suspicion?
1. The patient exhibits facial grimacing to painful stimuli but does not withdraw from the stimuli.
2. There is bilateral absence of deep tendon reflexes.
3. Laboratory results reveal elevation of creatine kinase level.
4. The patient exhibits diffuse weakness.
Answer: 1
Explanation: 1. One symptom of critical illness polyneuropathy is the demonstration of a painful stimuli being present, such as facial grimacing, without the ability to withdraw from the stimuli. This is because of a distal loss of pain reception abilities.
2. Deep tendon reflexes are preserved in critical illness polyneuropathy.
3. There is no laboratory test to diagnose critical illness polyneuropathy. Electrodiagnostic testing is necessary for diagnosis.
4. Critical illness polyneuropathy mainly affects the lower limb nerves. Diffuse weakness is characteristic of critical illness myelopathy.
12) An initiative for early identification of critical illness myopathy (CIM) has been undertaken by the nurses in the intensive care unit. These nurses would be most watchful of this complication in which patients?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
1. Patients who have type 1 diabetes mellitus
2. Patients with documented presence of renal calculi
3. Patients admitted with the diagnosis of status asthmaticus
4. Patients sedated with neuromuscular blocking agents
5. Patients who have received high-dose corticosteroid therapy
Answer: 3, 4, 5
Explanation: 1. Elevated glucose levels have been associated with critical illness polyneuropathy.
2. Renal calculi are not associated with CIM.
3. CIM is associated with status asthmaticus in approximately one third of these cases.
4. CIM is a spectrum of muscle disorders that present with diffuse weakness, depressed deep tendon reflexes, and mildly elevated creatine kinase levels. It has been associated with neuromuscular blocking agent use.
13) The nurse is providing care to a patient receiving a neuromuscular blocking agent. Which nursing intervention is most important specifically due to this medical intervention?
1. Monitor urine output.
2. Provide eye care.
3. Move the patient as little as possible.
4. Provide mouth care.
Answer: 2
Explanation: 1. Urine output should be monitored for all critically ill patients. This monitoring is not specific to patients under neuromuscular block.
2. Nursing care of a patient receiving a neuromuscular blocking agent should include prophylactic eye care. The nurse should keep the eyes closed and covered with a soft eye pad and use eye lubricants or artificial tears.
3. The patient receiving neuromuscular blockage will be unable to move self. The nurse must intervene with actions to prevent muscle contractures and skin breakdown.
4. Mouth care is an essential component of the care of all critically ill patients.
14) A patient in the intensive care unit begins to seize. The nurse would anticipate initial management of this seizure to include which intravenous medication?
1. Fosphenytoin
2. Lorazepam
3. Propofol
4. Diazepam
Answer: 2
Explanation: 1. Fosphenytoin would be administered if the first-line class of drugs were ineffective in controlling the seizure.
2. Intravenous benzodiazepines are effective in stopping seizures 65%-80% of the time. Lorazepam is the treatment of choice over diazepam because it lasts longer.
3. Propofol could be administered if the first- and second-line drugs are ineffective in controlling the seizure.
4. Diazepam is a benzodiazepine that can be administered intravenously; however, it does not last as long as the preferred drug.
15) A patient in the intensive care unit begins exhibiting seizure activity. What nursing interventions are indicated?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
1. Hold the patient as still as possible to prevent tissue damage.
2. Roll the patient to the side if possible.
3. Place a padded tongue blade in the patient’s mouth.
4. Time the seizure from beginning to end.
5. Call the rapid response team.
Answer: 2, 4
Explanation: 1. The nurse should remove hard objects if possible and pad objects that cannot or should not be removed. This action will help prevent injury. The nurse should not attempt to hold the patient still.
2. Rolling the patient to the side will allow secretions to clear the mouth and will help prevent aspiration.
3. No attempt to place anything in the patient’s mouth should be made.
4. Length of seizure is important assessment information that can be collected by the nurse.
5. The nurse working in the intensive care unit should be adequately prepared to manage a patient having a seizure. There is no need to call for a rapid response team for a simple seizure.
