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Chapter 59: Dementia and Delirium Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A patient who is hospitalized with pneumonia is disoriented and confused 3 days after

admission. Which information indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patient’s speech is fragmented and incoherent. c. The patient is oriented to person but disoriented to place and time. d. The patient has a history of increasing confusion over several years. ANS: A

The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia. DIF: Cognitive Level: Understand (comprehension) REF: 1400 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. Which intervention will the nurse include in the plan of care for a patient with moderate

dementia who had a fractured hip repair 2 days ago? Provide complete personal hygiene care for the patient. Remind the patient frequently about being in the hospital. Reposition the patient frequently to avoid skin breakdown. Place suction at the bedside to decrease the risk for aspiration.

a. b. c. d.

ANS: B

The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility. DIF: Cognitive Level: Apply (application) REF: 1403 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 3. When administering a mental status examination to a patient with delirium, the nurse should a. wait until the patient is well-rested. b. administer an anxiolytic medication. c. choose a place without distracting stimuli. d. reorient the patient during the examination. ANS: C

Because overstimulation by environmental factors can distract the patient from the task of answering the nurse’s questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient’s delirium.

DIF: Cognitive Level: Apply (application) REF: 1416 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 4. The nurse is concerned about a postoperative patient’s risk for injury during an episode of

delirium. The most appropriate action by the nurse is to secure the patient in bed using a soft chest restraint. ask the health care provider to order an antipsychotic drug. instruct family members to remain at the patient’s bedside and prevent injury. assign unlicensed assistive personnel (UAP) to stay with and reorient the patient.

a. b. c. d.

ANS: D

The priority goal is to protect the patient from harm. Having a UAP stay with the patient will ensure the patient’s safety. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have many side effects. Restraints are not recommended because they can increase the patient’s agitation and disorientation. DIF: Cognitive Level: Analyze (analysis) Apply (application) REF: 1412 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 5. A patient seen in the outpatient clinic is diagnosed with mild cognitive impairment (MCI).

Which action will the nurse include in the plan of care? Suggest a move into an assisted living facility. Schedule the patient for more frequent appointments. Ask family members to supervise the patient’s daily activities. Discuss the preventive use of acetylcholinesterase medications.

a. b. c. d.

ANS: B

Ongoing monitoring is recommended for patients with MCI. MCI does not usually interfere with activities of daily living, acetylcholinesterase drugs are not used for MCI, and an assisted living facility is not indicated for a patient with MCI. DIF: Cognitive Level: Apply (application) REF: 1405 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 6. The nurse is administering a mental status examination to a patient who has hypertension. The

nurse suspects depression when the patient responds to the nurse’s questions with c. “Wait, let me think about that.” d. “Who are those people over there?”

a. “Is that right?” b. “I don’t know.” ANS: B

Answers such as “I don’t know” are more typical of depression than dementia. The response “Who are those people over there?” is more typical of the distraction seen in a patient with delirium. The remaining two answers are more typical of a patient with mild to moderate dementia. DIF: Cognitive Level: Apply (application) REF: 1400 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 7. A patient is diagnosed with moderate dementia after multiple strokes. During assessment of

the patient, the nurse would expect to find

a. b. c. d.

excessive nighttime sleepiness. difficulty eating and swallowing. loss of recent and long-term memory. fluctuating ability to perform simple tasks.

ANS: C

Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient’s ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia. DIF: Cognitive Level: Understand (comprehension) REF: 1401 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 8. Which action will help the nurse determine whether a new patient’s confusion is caused by

dementia or delirium? Ask about a family history of dementia. Administer the Mini-Mental Status Exam. Use the Confusion Assessment Method tool. Obtain a list of the patient’s usual medications.

a. b. c. d.

ANS: C

The Confusion Assessment Method tool has been extensively tested in assessing delirium. The other actions will be helpful in determining cognitive function or risk factors for dementia or delirium, but they will not be useful in differentiating between dementia and delirium. DIF: Cognitive Level: Apply (application) REF: 1415 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 9. A 72-yr-old patient is brought to the clinic by the patient’s spouse, who reports that the patient

is unable to solve common problems around the house. To obtain information about the patient’s current mental status, which question should the nurse ask the patient? a. “Are you sad right now?” c. “What did you eat for lunch?” b. “How is your self-image?” d. “Where were you were born?” ANS: C

This question tests the patient’s short-term memory, which is decreased in the mild stage of Alzheimer’s disease or dementia. Asking the patient about her birthplace tests for remote memory, which is intact in the early stages. Questions about the patient’s emotions and selfimage are helpful in assessing emotional status, but they are not as helpful in assessing mental state. DIF: Cognitive Level: Apply (application) REF: 1406 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 10. A patient is being evaluated for Alzheimer’s disease (AD). The nurse explains to the patient’s

adult children that a. the most important risk factor for AD is a family history of the disorder. b. a diagnosis of AD is made only after other causes of dementia are ruled out. c. new drugs have been shown to reverse AD deterioration dramatically in some patients. d. brain atrophy detected by magnetic resonance imaging (MRI) would confirm the

diagnosis of AD. ANS: B

The diagnosis of AD is usually one of exclusion. Age is the most important risk factor for development of AD. Drugs may slow the deterioration but do not reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in other diseases as well and does not confirm a diagnosis of AD. DIF: Cognitive Level: Understand (comprehension) REF: 1405 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 11. Which nursing action will be most effective in ensuring daily medication compliance for a

patient with mild dementia? Setting the medications up monthly in a medication box Having the patient’s family member administer the medication Posting reminders to take the medications in the patient’s house Calling the patient weekly with a reminder to take the medication

a. b. c. d.

ANS: B

Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the drug. The other nursing actions will not be as effective in ensuring that the patient takes the medications. DIF: Cognitive Level: Analyze (analysis) REF: 1413 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 12. A patient who has severe Alzheimer’s disease (AD) is being admitted to the hospital for

surgery. Which intervention will the nurse include in the plan of care? Encourage the patient to discuss events from the past. Maintain a consistent daily routine for the patient’s care. Reorient the patient to the date and time every 2 to 3 hours. Provide the patient with current newspapers and magazines.

a. b. c. d.

ANS: B

Providing a consistent routine will decrease anxiety and confusion for the patient. Reorientation to time and place will not be helpful to the patient with severe AD, and the patient will not be able to read. The patient with severe AD will probably not be able to remember events from the past. DIF: Cognitive Level: Apply (application) REF: 1414 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 13. A patient with Alzheimer’s disease (AD) who is being admitted to a long-term care facility

has had several episodes of wandering away from home. Which action will the nurse include in the plan of care? a. Reorient the patient several times daily. b. Have the family bring in familiar items. c. Place the patient in a room close to the nurses’ station. d. Ask the patient why the wandering episodes have occurred. ANS: C

Patients at risk for problems with safety require close supervision. Placing the patient near the nurse’s station will allow nursing staff to observe the patient more closely. The use of “why” questions can be frustrating for patients with AD because they are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patient’s short-term memory loss, reorientation will not help prevent wandering behavior. Because the patient had wandering behavior at home, familiar objects will not prevent wandering. DIF: Cognitive Level: Apply (application) REF: 1412 TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 14. The day shift nurse at the long-term care facility learns that a patient with dementia

experienced sundowning late in the afternoon on the previous two days. Which action should the nurse take? a. Have the patient take a mid-morning nap. b. Keep window blinds open during the day. c. Provide hourly orientation to time and place. d. Move the patient to a quiet room in the afternoon. ANS: B

A likely cause of sundowning is a disruption in circadian rhythms, and keeping the patient active and in daylight will help reestablish a more normal circadian pattern. Moving the patient to a different room might increase confusion. Taking a nap will interfere with nighttime sleep. Hourly orientation will not be helpful in a patient with dementia. DIF: Cognitive Level: Apply (application) REF: 1411 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 15. The nurse’s initial action for a patient with moderate dementia who develops increased

restlessness and agitation should be to a. reorient the patient to time, place, and person. b. administer a PRN dose of lorazepam (Ativan). c. assess for factors that might be causing discomfort. d. assign unlicensed assistive personnel (UAP) to stay in the patient’s room. ANS: C

Increased motor activity in a patient with dementia is frequently the patient’s only way of responding to factors such as pain, so the nurse’s initial action should be to assess the patient for any precipitating factors. Administration of sedative drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia. Assigning UAP to stay with the patient may also be necessary, but any physical changes that may be causing the agitation should be addressed first. DIF: Cognitive Level: Analyze (analysis) REF: 1411 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 16. When administering the Mini-Cog exam to a patient with possible Alzheimer’s disease, which

action will the nurse take? a. Check the patient’s orientation to time and date. b. Obtain a list of the patient’s prescribed medications.

c. Ask the person to use a clock drawing to indicate a specific time. d. Determine the patient’s ability to recognize a common object such as a pen. ANS: C

In the Mini-Cog, patients illustrate a specific time stated by the examiner by drawing the time on a clock face. The other actions may be included in assessment for Alzheimer’s disease but are not part of the Mini-Cog exam. DIF: Cognitive Level: Understand (comprehension) REF: 1408 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 17. Which hospitalized patient will the nurse assign to the room closest to the nurses’ station? a. Patient with Alzheimer’s disease who has long-term memory deficit b. Patient with vascular dementia who takes medications for depression c. Patient with new-onset confusion, restlessness, and irritability after surgery d. Patient with dementia who has an abnormal Mini-Mental State Examination ANS: C

This patient’s history and clinical manifestations are consistent with delirium. The patient is at risk for safety problems and should be placed near the nurses’ station for ongoing observation. The other patients have chronic symptoms that are consistent with their diagnoses but are not at immediate risk for safety issues. DIF: Cognitive Level: Analyze (analysis) OBJ: Special Questions: Multiple Patients MSC: NCLEX: Safe and Effective Care Environment

REF: 1415 TOP: Nursing Process: Planning

18. After change-of-shift report on the Alzheimer’s disease/dementia unit, which patient will the

nurse assess first? Patient who has not had a bowel movement for 5 days Patient who has a stage II pressure ulcer on the coccyx Patient who is refusing to take the prescribed medications Patient who developed a new cough after eating breakfast

a. b. c. d.

ANS: D

A new cough after a meal in a patient with dementia suggests possible aspiration, and the patient should be assessed immediately. The other patients also require assessment and intervention but not as urgently as a patient with possible aspiration or pneumonia. DIF: Cognitive Level: Analyze (analysis) REF: 1413 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 19. After reviewing the health record shown in the accompanying figure for a patient who has

multiple risk factors for Alzheimer’s disease (AD), which topic will be most important for the nurse to discuss with the patient?

a. Tobacco use b. Family history

c. Cholesterol level d. Head injury history

ANS: A

Tobacco use is a modifiable risk factor for AD. The patient will not be able to modify the increased risk associated with family history of AD and past head injury. While the total cholesterol is borderline high, the high HDL indicates that no change is needed in cholesterol management. DIF: Cognitive Level: Analyze (analysis) REF: 1402 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 1. The spouse of a 67-yr-old male patient with early stage Alzheimer’s disease (AD) tells the

nurse, “I am exhausted from worrying all the time. I don’t know what to do.” Which actions are best for the nurse to take next (select all that apply)? a. Suggest that a long-term care facility be considered. b. Offer ideas for ways to distract or redirect the patient. c. Teach the spouse about adult day care as a possible respite. d. Suggest that the spouse consult with the physician for antianxiety drugs. e. Ask the spouse what she knows and has considered about dementia care options. ANS: B, C, E

The stress of being a caregiver can be managed with a multicomponent approach. This includes respite care, learning ways to manage challenging behaviors, and further assessment of what the spouse may already have considered for care options. The patient is in the early stages and does not need long-term placement. Antianxiety medications may be appropriate, but other measures should be tried first. DIF: Cognitive Level: Apply (application) REF: 1411 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 2. Which actions could the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)

who is part of the team caring for a patient with Alzheimer’s disease (select all that apply)? a. Develop a plan to minimize difficult behavior. b. Administer the prescribed memantine (Namenda). c. Remove potential safety hazards from the patient’s environment. d. Refer the patient and caregivers to appropriate community resources. e. Help the patient and caregivers choose memory enhancement methods. f. Evaluate the effectiveness of the prescribed enteral feedings on patient nutrition. ANS: B, C

LPN/LVN education and scope of practice includes medication administration and monitoring for environmental safety in stable patients. Planning of interventions such as ways to manage behavior or improve memory, referrals, and evaluation of the effectiveness of interventions require registered nurse (RN)–level education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 1412 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment...