Chapter 23

Question 1

1.	An older adult patient takes multiple medications daily. 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.

Question 2

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, even though no sensory stimulus is actually present. This description meets 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.

Question 3

3. A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, “Someone get these bugs off me.” What is the nurse’s best response?
   a.
   “No bugs are on your legs. You are having hallucinations.”
   b.
   “I will have someone stay here and brush off the bugs for you.”
   c.
   “Try to relax. The crawling sensation will go away sooner if you can relax.”
   d.
   “I don’t see any bugs, but I can tell you are frightened. 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 support the patient emotionally. 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.

Question 4

4. What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?
   a.
   Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment
   b.
   Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks
   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 visual and tactile hallucinations

Answer 4

ANS: A
The physical safety of the patient is of highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful or when the patient exercises poor judgment or when the patient’s sensorium is clouded. The other diagnoses may be concerns, but are lower priorities.

Question 5

5.	What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations?
a.
Distraction using sensory stimulation
b.
Careful observation and supervision
c.
Avoidance of physical contact
d.
Activation of the bed alarm

Answer 5

ANS: B
Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient will remain safe and free from injury. Physical contact during care cannot be avoided. Activating a bed alarm is only one aspect of providing for the

Question 6

6. A patient diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this patient?
   a.
   Provide a well-lit room without glare or shadows. Limit noise and stimulation.
   b.
   Maintain soft lighting day and night. Keep a radio on low volume continuously.
   c.
   Light the room brightly day and night. Awaken the patient hourly to assess mental status.
   d.
   Keep the patient by the nurse’s desk while awake. Provide rest periods in a room with a television on.

Answer 6

ANS: A
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.

Question 7

7. Which assessment finding would be likely for a patient experiencing a hallucination? The 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.
   reports telepathic messages from the television.
   d.
   speaks in rhymes.

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 other incorrect options apply to thought insertion and clang associations.

Question 8

8.	Consider these cerebral pathophysiologies: Lewy body development, frontotemporal degeneration, and accumulation of protein β-amyloid. Which diagnosis applies?
a.
Cyclothymia
b.
Dementia
c.
Delirium
d.
Amnesia

Answer 8

ANS: B

The listed cerebral pathophysiologies are all associated with development of dementia.

Question 9

9.	Which medication prescribed to patients diagnosed with Alzheimer’s disease antagonizes N-methyl-D-aspartate (NMDA) channels rather than cholinesterase?
a.
Donepezil
b.
Rivastigmine
c.
Memantine
d.
Galantamine

Answer 9

ANS: C
Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterace inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimer’s disease.

Question 10

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.
Anhedonia

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. Anhedonia refers to a loss of joy in life.

Question 11

11.	An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police intervened, they found that this adult was wearing a heavy coat and hat, even though it was July. Which stage of Alzheimer’s disease is evident?
a.
Sundowning
b.
Early
c.
Middle
d.
Late

Answer 11

ANS: C
In the middle stage, 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. The individual has difficulty with clothing selection. Mild cognitive decline (early-stage) Alzheimer’s can be diagnosed in some, but not all, individuals. Symptoms include misplacing items and misuse of words. In the late stage there is severe cognitive decline along with agraphia, hyperorality, blunting of emotions, visual agnosia, and hypermetamorphosis. Sundowning is not a stage of Alzheimer’s disease.

Question 12

12.	Consider these phenomena: accumulation of β-amyloid outside the neurons, neurofibrillary tangles, and neuronal degeneration in the hippocampus. Which health problem corresponds to these events?
a.
Huntington’s disease
b.
Alzheimer’s disease
c.
Parkinson’s disease
d.
Vascular dementia

Answer 12

ANS: B
The pathophysiological phenomena described apply to Alzheimer’s disease. Parkinson’s disease is associated with dopamine dysregulation. Huntington’s disease is genetic. Vascular dementia is the consequence of circulatory changes.

Question 13

13.	A patient diagnosed as mild stage 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.
Self-care deficit
b.
Impaired memory
c.
Caregiver role strain
d.
Adult failure to thrive

Answer 13

ANS: B
Memory impairment begins at the mild stage and progresses in the subsequent stages. This patient is able to perform most self-care activities. Caregiver role strain and adult failure to thrive occur later.

Question 14

14. A patient has progressive memory deficits 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.
    Read one story from the newspaper to the patient every day.

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 enjoy the attention of someone reading to them, but this activity does not promote their function in the environment.

Question 15

15. Two patients in a residential care facility are diagnosed with dementia. One shouts to the other, “Move along, you’re blocking the road.” The other patient turns, shakes a fist, and shouts, “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 probably is 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.

Question 16

16. An older adult patient in the intensive care unit is experiencing visual illusions. Which intervention will be most helpful?
    a.
    Use the patient’s glasses.
    b.
    Place personally meaningful objects in view.
    c.
    Position large clocks and calendars on the wall.
    d.
    Assure that the room is brightly lit but very quiet at all times.

Answer 16

ANS: A
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.

Question 17

17.	A patient diagnosed with Alzheimer’s disease calls the fire department saying, “My smoke detectors are going off.” Firefighters investigate and discover that the patient misinterpreted the telephone ringing. Which problem is this patient experiencing?
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.

Question 18

18.	During morning care, a nurse asks a patient diagnosed 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 refers to 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.

Question 19

19.	A nurse counsels the family of a patient diagnosed with Alzheimer’s disease who lives at home and wanders at night. Which action is most important for the nurse to recommend for enhancing safety?
a.
Apply a medical alert bracelet to the patient.
b.
Place locks at the tops of doors.
c.
Discourage 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. The patient will try to climb over side rails, increasing the risk for injury and falls. Avoiding daytime naps may improve the patient’s sleep pattern but does not assure safety. A medical alert bracelet will be helpful if the patient leaves the home, but it does not prevent wandering or assure the patient’s safety.

Question 20

20. Goals of care for an older adult patient diagnosed 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 delirious patient will return to the level of functioning held before the development of delirium. Demonstrating motor response to noxious stimuli is an indicator appropriate 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 a patient with sensorium problems related to delirium.

Question 21

21. An older adult with moderately severe 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 briefs.
    d.
    Limit the intake of oral fluids to 1000 mL/day.

Answer 21

ANS: A
The patient with moderately severe dementia 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 briefs is more appropriate at a later stage. Severely limiting oral fluid intake would predispose the patient to a urinary tract infection.

Question 22

22. A older patient diagnosed with severe, late-stage dementia no longer recognizes family members. The family asks how long it will be before this patient 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 the family to come to terms with the losses and irreversibility dementia imposes on both the loved one and themselves. Two incorrect responses close communication. The nurse should take the opportunity to foster communication. Consciousness does not fluctuate in patients with dementia.

Question 23

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.
    Place large clocks and calendars strategically.

Answer 23

ANS: B
Reorientation may seem like arguing to a patient with cognitive deficit 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 placing large clocks and calendars strategically are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable because patients with dementia sometimes become more agitated with reorientation.

Question 24

24.	What is the priority need for a patient diagnosed with severe, late-stage dementia?
a.
Promotion of self-care activities
b.
Meaningful verbal communication
c.
Preventing the patient from wandering
d.
Maintenance of nutrition and hydration

Answer 24

ANS:	D
In severe (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.

Question 25

25.	An older adult is prescribed digoxin and hydrochlorothiazide daily as well as lorazepam as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the patient’s change in mental status?
a.
Drug actions and interactions
b.
Benzodiazepine withdrawal
c.
Hypotensive episodes
d.
Renal failure

Answer 25

ANS: A
Drug actions and interactions are common among elderly persons and predispose this population to delirium. Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The patient takes lorazepam on a prn basis, so withdrawal is unlikely. Hypotensive episodes or problems with renal function may occur associated with the patient’s drug regime, but interactions are more likely the problem.

Question 26

26.	A hospitalized patient diagnosed with delirium misinterprets reality. A patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? The patients will
a.
remain safe in the 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. Safety maintenance is the desired outcome. The other outcomes are lower priorities and may not be realistic.

Question 27

27. An elderly patient is admitted with delirium secondary to a urinary tract infection. The family asks whether the patient will ever recover. Select the nurse’s best response.
    a.
    “The health care provider is the best person to answer your question.”
    b.
    “The confusion will probably get better as we treat the infection.”
    c.
    “Unfortunately, delirium is a progressively disabling disorder.”
    d.
    “I will be glad to contact the chaplain to talk with you.”

Answer 27

ANS: B
Usually, as the underlying cause of the delirium is treated, the symptoms of delirium clear. The distracters mislead the family.

Question 28

28. An elderly person presents with symptoms of delirium. The family reports, “Everything was fine until yesterday.” What is the most important assessment information for the nurse to gather?
    a.
    A list of all medications the person currently takes
    b.
    Whether the person has experienced any recent losses
    c.
    Whether the person has ingested aged or fermented foods
    d.
    The person’s recent personality characteristics and changes

Answer 28

ANS: A
Delirium is often the result of medication interactions or toxicity. The distracters relate to MAOI (monoamine oxidase inhibitor) therapy and depression.

Question 29

29.	A nurse gives anticipatory guidance to the family of a patient diagnosed with mild early stage Alzheimer’s disease. Which problem common to that stage should the nurse address?
a.
Violent outbursts
b.
Emotional disinhibition
c.
Communication deficits
d.
Inability to feed or bathe self

Answer 29

ANS: C
Families should be made aware that the patient will have difficulty concentrating and following or carrying on in-depth or lengthy conversations. The other symptoms and problems are usually seen at later stages of the disease.

Question 30

1. A patient diagnosed with moderate stage Alzheimer’s disease has a self-care deficit of dressing and grooming. Designate 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 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 dressing, use distraction and try again after a short interval.

Answer 30

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 (provides information if the patient has agnosia). When a patient resists, it is appropriate to use distraction and try again after a short interval because patient’s moods are often labile. The patient may be willing to cooperate given a later opportunity. Providing the necessary items for grooming and directing the patient to proceed independently are inappropriate. Be 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.

Question 31

2.	Which assessment findings would the nurse expect in a patient experiencing delirium? (Select all that apply.)
a.
Impaired level of consciousness
b.
Disorientation to place, time
c.
Wandering attention
d.
Apathy
e.
Agnosia

Answer 31

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.

Question 32

3.	Which nursing diagnoses are most applicable for a patient diagnosed with severe late stage Alzheimer’s disease? (Select all that apply.)
a.
Acute confusion
b.
Anticipatory grieving
c.
Urinary incontinence
d.
Disturbed sleep pattern
e.
Risk for caregiver role strain

Answer 32

ANS: C, D, E
The correct answers are consistent with problems frequently identified for patients with late-stage Alzheimer’s disease. Confusion is chronic, not acute. The patient’s cognition is too impaired to grieve.