Chapter 60: Nursing Management: Alzheimers Disease, Dementia, and Delirium My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 60: Nursing Management: Alzheimers Disease, Dementia, and Delirium

Test Bank

MULTIPLE CHOICE

1. A patient who is hospitalized with pneumonia is disoriented and confused 2 days after admission. Which information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia?

a.

The patient was oriented and alert when admitted.

b.

The patients speech is fragmented and incoherent.

c.

The patient is disoriented to place and time but oriented to person.

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: Comprehension REF: 1521

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse include?

a.

Provide complete personal hygiene care for the patient.

b.

Remind the patient frequently about being in the hospital.

c.

Reposition the patient frequently to avoid skin breakdown.

d.

Place suction at the bedside to decrease the risk for aspiration.

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: Application REF: 1522 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

3. When administering a mental status examination to a patient with delirium, the nurse should

a.

medicate the patient first to reduce any anxiety.

b.

give the examination when the patient is well-rested.

c.

reorient the patient as needed during the examination.

d.

choose a place without distracting environmental stimuli.

ANS: D

Because overstimulation by environmental factors can distract the patient from the task of answering the nurses 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 patients delirium.

DIF: Cognitive Level: Application REF: 1535-1537

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

4. To protect a patient from injury during an episode of delirium, the most appropriate action by the nurse is to

a.

secure the patient in bed using a soft chest restraint.

b.

ask the health care provider about ordering an antipsychotic drug.

c.

instruct family members to remain with the patient and prevent injury.

d.

assign a nursing assistant to stay with the patient and offer frequent reorientation.

ANS: D

The priority goal is to protect the patient from harm, and a staff member will be most experienced in providing safe care. 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 multiple side effects. Restraints are sometimes used but tend to increase agitation and disorientation.

DIF: Cognitive Level: Application REF: 1535 | 1537

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

5. Which action will the nurse in the outpatient clinic include in the plan of care for a patient with mild cognitive impairment (MCI)?

a.

Suggest a move into an assisted living facility.

b.

Schedule the patient for more frequent appointments.

c.

Ask family members to supervise the patients daily activities.

d.

Discuss the preventive use of acetylcholinesterase medications.

ANS: B

Ongoing monitoring is recommended for patients with MCI. MCI does not interfere with activities of daily living, acetylcholinesterase drugs are not used for MCI, and an assisted living facility is not indicated for MCI.

DIF: Cognitive Level: Application REF: 1522-1523 TOP: Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity

6. When administering a mental status examination to a patient, the nurse suspects depression when the patient responds with

a.

I dont know.

b.

Is that the right answer?

c.

Wait, let me think about that.

d.

Who are those people over there?

ANS: A

Answers such as I dont know are more typical of depression. 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 dementia.

DIF: Cognitive Level: Application REF: 1521

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

7. A 72-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During assessment of the patient, the nurse would expect to find

a.

excessive nighttime sleepiness.

b.

difficulty eating and swallowing.

c.

variable ability to perform simple tasks.

d.

loss of both recent and long-term memory.

ANS: D

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 patients ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia.

DIF: Cognitive Level: Comprehension REF: 1522

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

8. To determine whether a new patients confusion is caused by dementia or delirium, which action should the nurse take?

a.

Assess the patient using the Mini-Mental Status Exam.

b.

Obtain a list of the medications that the patient usually takes.

c.

Determine whether there is positive family history of dementia.

d.

Use the Confusion Assessment Method tool to assess the patient.

ANS: D

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: Application REF: 1535-1537

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

9. A 62-year-old patient is brought to the clinic by a family member who is concerned about the patients inability to solve common problems. To obtain information about the patients current mental status, which question should the nurse ask the patient?

a.

Where were you were born?

b.

Do you have any feelings of sadness?

c.

What did you have for breakfast?

d.

How positive is your self-image?

ANS: C

This question tests the patients recent memory, which is decreased early in Alzheimers disease (AD) or dementia. Asking the patient about birthplace tests for remote memory, which is intact in the early stages. Questions about the patients emotions and self-image are helpful in assessing emotional status, but they are not as helpful in assessing mental state.

DIF: Cognitive Level: Application REF: 1527

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

10. When teaching the children of a patient who is being evaluated for Alzheimers disease (AD) about the disorder, the nurse explains that

a.

the most important risk factor for AD is a family history of the disorder.

b.

new drugs have been shown to reverse AD dramatically in some patients.

c.

a diagnosis of AD can be made only when other causes of dementia have been ruled out.

d.

the presence of brain atrophy detected by MRI confirms the diagnosis of AD in patients with dementia.

ANS: C

The diagnosis of AD is one of exclusion. Age is the most important risk factor for development of AD. Drugs can slow the deterioration but do not dramatically 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 an AD diagnosis.

DIF: Cognitive Level: Comprehension REF: 1527

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

11. A patient with mild dementia has a new prescription for donepezil (Aricept). Which nursing action will be most effective in ensuring compliance with the medication?

a.

Having the patients spouse administer the medication

b.

Setting the medications up weekly in a medication box

c.

Calling the patient daily with a reminder to take the medication

d.

Posting reminders to take the medications in the patients house

ANS: A

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: Application REF: 1522

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

12. Which intervention will the nurse include in the plan of care for a patient who has late-stage Alzheimers disease (AD)?

a.

Encourage the patient to discuss events from the past.

b.

Maintain a consistent daily routine for the patients care.

c.

Reorient the patient to the date and time every 2 to 3 hours.

d.

Provide the patient with current newspapers and magazines.

ANS: B

Providing a consistent routine will decrease anxiety and confusion for the patient. In late-stage AD, the patient will not remember events from the past. Reorientation to time and place will not be helpful to the patient with late-stage AD, and the patient will not be able to read.

DIF: Cognitive Level: Application REF: 1522 | 1527 | 1534

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

13. When assessing a patient with Alzheimers disease (AD) who is being admitted to a long-term care facility, the nurse learns that the patient has had several episodes of wandering away from home. Which nursing action will the nurse include in the plan of care?

a.

Place the patient in a room close to the nurses station.

b.

Ask the patient why the wandering episodes have occurred.

c.

Have the family bring in familiar items from the patients home.

d.

Reorient the patient to the new living situation several times daily.

ANS: A

Patients at risk for problems with safety require close supervision. Placing the patient near the nurses station will allow nursing staff to observe the patient more closely. The use of why questions is frustrating for patients with AD because they are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patients 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: Application REF: 1530-1531 TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

14. During the morning change-of-shift report at the long-term care facility, the nurse learns that the patient with dementia has had sundowning. Which nursing action should the nurse take while caring for the patient?

a.

Provide hourly orientation to time of day.

b.

Move the patient to a quieter room at night.

c.

Keep blinds open during the daytime hours.

d.

Have the patient take a brief mid-morning nap.

ANS: C

The most likely cause of sundowning is a disruption in circadian rhythms and keeping the patient active and in daylight will help to 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 memory difficulties.

DIF: Cognitive Level: Application REF: 1531-1532

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

15. A long-term care patient with moderate dementia develops increased restlessness and agitation. The nurses initial action should be to

a.

reorient the patient to time, place, and person.

b.

administer the PRN dose of lorazepam (Ativan).

c.

assess for factors that might be causing discomfort.

d.

have a nursing assistant stay with the patient to ensure safety.

ANS: C

Increased motor activity in a patient with dementia is frequently the patients only way of responding to factors like pain, so the nurses 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 a nursing assistant to stay with the patient also may be necessary, but any physical changes that may be causing the agitation should be addressed first.

DIF: Cognitive Level: Application REF: 1529-1531

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. The spouse of a male patient with early stage Alzheimers disease (AD) tells the nurse, I am just exhausted from the constant worry. I dont know what to do. Which action is 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.

Suggest that the spouse consult with the physician for antianxiety drugs.

d.

Educate the spouse about the availability of adult day care as a respite.

e.

Ask the spouse what she knows and has considered about dementia care options.

ANS: B, D, 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. 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: Application REF: 1529-1533 | 1534

OBJ: Special Questions: Alternate Item Format

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

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