Deck 62: Nursing Management Delirium

Question 1

The nurse is assessing a client who is diagnosed with middle (moderate) dementia as a result of multiple strokes. Which of the following findings should the nurse expect?

A)Excessive nighttime sleepiness
B)Difficulty eating and swallowing
C)Variable ability to perform simple tasks
D)Loss of both recent and remote memory

Answer 1

Loss of both recent and remote memory

Question 2

To determine whether a new client's confusion is caused by dementia or delirium, which of the following actions should the nurse take?

A)Assess the client using the Mini-Mental Status Exam.
B)Obtain a list of the medications that the client usually takes.
C)Determine whether there is positive family history of dementia.
D)Use the Confusion Assessment Method tool to assess the client.

Answer 2

Use the Confusion Assessment Method tool to assess the client.

Question 3

The nurse is caring for a long-term care client with moderate dementia who develops increased restlessness and agitation. Which of the following actions should the nurse implement initially?

A)Reorient the client to time, place, and person.
B)Administer the PRN dose of lorazepam.
C)Assess for factors that might be causing discomfort.
D)Have a nursing assistant stay with the client to ensure safety.

Answer 3

Assess for factors that might be causing discomfort.

Question 4

The nurse is assessing a client with Alzheimer's disease (AD) who is being admitted to a long-term care facility and the nurse learns that the client has had several episodes of wandering away from home. Which of the following nursing actions should thenurseinclude in the plan of care?

A)Place the client in a room close to the nurses' station.
B)Ask the client why the wandering episodes have occurred.
C)Have the family bring in familiar items from the client's home.
D)Reorient the client to the new living situation several times daily.

Question 5

The nurse is caring for a client who is hospitalized with pneumonia and is disoriented and confused 2 days after admission. Which of the following information obtained by the nurse about the client indicates that the client is experiencing delirium rather thandementia?

A)The client was oriented and alert when admitted.
B)The client's speech is fragmented and incoherent.
C)The client is disoriented to place and time but oriented to person.
D)The client has a history of increasing confusion over several years.

Question 6

Which of the following actions should the nurse in the outpatient clinic include in the plan of care for a client with mild cognitive impairment (MCI)?

A)Suggest a move into an assisted-living facility.
B)Schedule the client for annual appointments.
C)Ask family members to supervise the client's daily activities.
D)Discuss the preventive use of acetylcholinesterase medications.

Question 7

The nurse is caring for a client with dementia with lewy bodies (DLB). Which of the following complications is the client most at risk for developing related to DLB?

A)Stroke
B)Pneumonia
C)Myocardial infarction
D)Urinary tract infection

Question 8

The nurse is administering a mental status examination to a client. Which of the following client responses should lead the nurse to suspect possible depression?

A)"I don't know."
B)"Is that the right answer?"
C)"Wait, let me think about that."
D)"Who are those people over there?"

Question 9

The nurse is caring for a client with Alzheimer's disease. A family member asks the nurse which of the client's medication is to treat the decreased memory and cognition. Which of the following medications is used to treat this problem associated with Alzheimer's disease?

A)Sertraline
B)Citalopram
C)Rivastigmine
D)Risperidone

Question 10

The nurse is teaching the children of a client who is being evaluated for Alzheimer's disease (AD) about the disorder. Which of the following information should the nurse include?

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 clients.
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 clients with dementia.

Question 11

Which of the following interventions should the nurse include in the plan of care for a client who has late-stage Alzheimer's disease (AD)?

A)Encourage the client to discuss events from the past.
B)Maintain a consistent staff member for the client's care.
C)Reorient the client to the date and time every 2-3 hours.
D)Provide the client with current newspapers and magazines.

Question 12

The partner of a client with early stage Alzheimer's disease (AD) tells the nurse, "I am just exhausted from the constant worry. I don't know what to do." Which of the following actions 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 client.
C)Suggest that the partner consult with the physician for antianxiety drugs.
D)Educate the partner about the availability of adult day care as a respite.
E)Ask the partner what has been considered about dementia care options.

Question 13

Which of the following actions is most appropriate for the nurse to implement to protect a client from injury during an episode of delirium?

A)Secure the client 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 client and prevent injury.
D)Assign a nursing assistant to stay with the client and offer frequent reorientation.

Question 14

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

A)Provide hourly orientation to time of day.
B)Move the client to a quieter room at night.
C)Keep blinds open during the daytime hours.
D)Have the client take a brief mid-morning nap.

Question 15

The nurse is developing a plan of care for a hospitalized client with moderate dementia. Which of the following interventions should the nurse include?

A)Provide complete personal hygiene care for the client.
B)Remind the client frequently about being in the hospital.
C)Reposition the client frequently to avoid skin breakdown.
D)Place suction at the bedside to decrease the risk for aspiration.

Question 16

The nurse is caring for a client with mild dementia who has a new prescription for donepezil. Which of the following nursing actions is most effective in ensuring compliance with the medication?

A)Having the client's partner administer the medication
B)Setting the medications up weekly in a medication box
C)Calling the client daily with a reminder to take the medication
D)Posting reminders to take the medications in the client's house