Cognition practice Flashcards
Consequences of cognitive impairment include:
Increased risk for injury
Complicates disease management
Decreased functional ability, including capacity for independent living and normal social interaction
Increased need for assistive services
Financial hardship
Caregiver burden
u L.K. is a 76-year-old male who has been in the intensive care unit (ICU) for 2 days after having major abdominal surgery. He is becoming increasingly confused and agitated. Before surgery, he was alert and oriented.
Subjective Data
u •States he needs to “get out of here”
u •Angry at family members for not “taking me home”
u •Family members are very upset about M.C.’s confusion
Objective Data
u •Blood pressure 110/70, pulse 98, respirations 20,
temperature 97.3o F
u •Oxygen saturation 97% on nasal cannula oxygen at 2L
u •Abdominal incision healing, no redness or drainage
u •Difficulty speaking with decreased short-term memory and recall
u •Trying to climb out of bed u •Oriented to person only
What type of cognitive impairment does the patient likely have?
Delirium
Rationale: the patient is exhibiting symptoms of delirium, which is a temporary but acute ,rental confusion that is common in the hospitalised elderly
u L.K. is a 76-year-old male who has been in the intensive care unit (ICU) for 2 days after having major abdominal surgery. He is becoming increasingly confused and agitated. Before surgery, he was alert and oriented.
Subjective Data
u •States he needs to “get out of here”
u •Angry at family members for not “taking me home”
u •Family members are very upset about M.C.’s confusion
Objective Data
u •Blood pressure 110/70, pulse 98, respirations 20,
temperature 97.3o F
u •Oxygen saturation 97% on nasal cannula oxygen at 2L
u •Abdominal incision healing, no redness or drainage
u •Difficulty speaking with decreased short-term memory and recall
u •Trying to climb out of bed u •Oriented to person only
Are there any other issues that you need to consider as possible causes for his mental state?
There is the possibility of: alcohol withdrawal, early onset of hypoxia, infection, sensory deprivation, sleep deprivation, dehydration, electrolyte imbalance, hypoglycaemia, and effect of multiple medications
u L.K. is a 76-year-old male who has been in the intensive care unit (ICU) for 2 days after having major abdominal surgery. He is becoming increasingly confused and agitated. Before surgery, he was alert and oriented.
Subjective Data
u •States he needs to “get out of here”
u •Angry at family members for not “taking me home”
u •Family members are very upset about M.C.’s confusion
Objective Data
u •Blood pressure 110/70, pulse 98, respirations 20,
temperature 97.3o F
u •Oxygen saturation 97% on nasal cannula oxygen at 2L
u •Abdominal incision healing, no redness or drainage
u •Difficulty speaking with decreased short-term memory and recall
u •Trying to climb out of bed u •Oriented to person only
What is the nurse’s priority regarding the patient’s mental status?
Safety is the FIRST concern.
The nurse needs to provide a quiet, safe, and calming environment; use frequent reorienting strategies, including reassurance, reorienting information, encouraging a family member to stay at the bedside, and planning for consistency of staff caring for the patient.
If the patient wears glasses or has a hearing aid, make sure the patient has those items.
u L.K. is a 76-year-old male who has been in the intensive care unit (ICU) for 2 days after having major abdominal surgery. He is becoming increasingly confused and agitated. Before surgery, he was alert and oriented.
u Subjective Data
u •States he needs to “get out of here”
u •Angry at family members for not “taking me home”
u •Family members are very upset about M.C.’s confusion
u Objective Data
u •Blood pressure 110/70, pulse 98, respirations 20,
temperature 97.3o F
u •Oxygen saturation 97% on nasal cannula oxygen at 2L
u •Abdominal incision healing, no redness or drainage
u •Difficulty speaking with decreased short-term memory and recall
u •Trying to climb out of bed u •Oriented to person only
What is included with the collaborative care for the family at this time?
The family will be educated and provided reassurance that delirium is typically an acute condition. If no other medical problems are encountered, L.K. Is likely to return to his former mental state after his condition stabilizes and/or he transfers from the ICU. Family members are encouraged to continue reorientation activities and not to react to his inappropriate statements.
Which symptoms distinguishes delirium from dementia?
-rapid onset of symptoms, often at night
-abrupt progression of disease
-accelerated, incoherent speech
When a patient’s cognition is being assessed, which functional characteristic would the nurse evaluate?
-ability to count backward from 100-7
-ability to name the last three presidents’
A patient undergoing the Mini-Cog test is being assessed for cognitive impairment. After the clock drawing test, the patient puts the numbers in correct sequence on the clock and recalls two words that the nurse asked the patient to remember. What is the test score for this patient?
the test score is 4 (-2 for the clock, +2 for the 2 words)
Which action would the nurse take when a patient with cognitive dysfunction due to stroke is unable to learn the self-care techniques taught by the nurse?
encourage the care giver to be more involved in patient care activities
The nurse is conduction a teaching session on health strategies to decrease the risk for developing Alzheimer Disease (AD). Which statement by a participant would indicate the need for further education?
“Drinking a few glasses of wine each day has been shown to decrease the incidence of AD.”
Which cognitive function typically declines with age?
-short term memory recall
-mental performance speed
-synthesis of new information
Which nursing intervention would the nurse use with a patient who has been diagnosed with the mild cognitive impairment stage of Alzheimer disease?
Use a calendar and family pictures as memory aids
Which symptom would the nurse assess if an older adult is showing signs of dementia?
-abrupt changes in behavior
-memory loss
-cognitive dysfunction
Which finding would the nurse identify as supporting a diagnosis of dementia in a patient with behavioral changes?
-difficulty with normal conversation
-loss of memory
Which cognitive change is characteristic of a patient experiencing hypoxia?
-restlessness
-apprehension
-memory changes
