Question 1

A patient diagnosed with delirium stares at the corner of the room, wrings hands, and says, "I'm scared those snakes will bite me." What term should the nurse use to best document this event?

Accepted Answer

The patient is experiencing a visual hallucination, as they are seeing snakes in the room that are not actually there. Agnosia refers to difficulty recognizing sensory information, disorientation refers to confusion about time, place, or person, and confabulation refers to creating false memories or experiences.

Question 2

The focus of nursing care for a patient diagnosed with dementia is best demonstrated by which nursing statement?

Accepted Answer

C

Question 3

An older adult patient developed delirium secondary to diphenhydramine use.The patient usually took this drug for allergies but recently added a cough syrup that also contained the drug.What information is most important to teach the family?

Accepted Answer

Older adults often have slower metabolism, which can lead to toxic levels of medications like diphenhydramine, increasing the risk of delirium.

Question 4

The nurse teaches a family who provides in-home care for a patient diagnosed with dementia.Which measure to facilitate environmental safety should the nurse include?

Accepted Answer

Installing gates at the tops and bottoms of stairs can prevent falls and injuries for patients with dementia who may have impaired mobility and judgment. Storing medications in a clearly visible place and varying the daily schedule for stimulation are also important measures, but they do not directly address environmental safety. Including daily activities that call for use of higher cognitive functions is beneficial for the patient's cognitive health, but it does not specifically address environmental safety concerns.

Question 5

What is the foundation of the cognitive process?

Accepted Answer

The foundation of the cognitive process is memory and learning, as these are the essential building blocks of virtually all higher-level cognitive functions, from perception and attention to reasoning and problem-solving. Without memory and learning, we would be unable to form associations between different elements of our environment, recognize patterns or anticipate future events.

Question 6

A patient diagnosed with dementia is watching a crime story on television.Suddenly, the patient begins to yell, "Stop! He's got a gun." What is the nurse's best intervention?

Accepted Answer

Turning off the television and reassuring the patient that they are safe is the best intervention in this situation. The patient's reaction is likely due to confusion and fear caused by their dementia, and administering medication or providing a snack will not address the underlying issue. It is important to validate the patient's feelings and provide a calm and reassuring environment.

Question 7

The family of a patient diagnosed with Alzheimer disease (AD) is concerned about the patient's occasional urinary incontinence.The nurse should give which suggestion?

Accepted Answer

Taking the patient to the bathroom every 2 hours is the best suggestion because it promotes continence and prevents accidents. Using adult diapers may be necessary at times, but it does not address the underlying issue and may lead to skin breakdown or infections. Putting a sign on the bathroom door may not be effective if the patient forgets or does not understand the sign. Limiting fluid intake to 1000 mL daily can cause dehydration and other health problems.

Question 8

An older adult patient is admitted with a diagnosis of delirium secondary to a urinary tract infection.The family asks whether or not the patient will recover.Select the nurse's best response.

Accepted Answer

Delirium is often caused by an underlying medical condition, such as a urinary tract infection. Once the infection is treated, the symptoms of delirium usually improve. Therefore, the nurse's best response is to provide reassurance that the confusion is likely to improve with treatment of the infection.

Question 9

An older adult presents with symptoms of delirium.The family says, "Everything was fine until yesterday." What is the most important assessment information the nurse should gather?

Accepted Answer

A list of medications the patient currently takes is crucial because many medications can cause or contribute to delirium, especially in older adults who may be more sensitive to side effects or interactions.

Question 10

What is the expected outcome for donepezil therapy prescribed for a client diagnosed with mild-to-moderate Alzheimer disease (AD)?

Accepted Answer

Donepezil therapy is expected to provide better daily function than without treatment for clients diagnosed with mild-to-moderate AD. It may also slow down the progression of symptoms, but it does not offer a cure or remissions. It may improve memory and cognitive function to some degree, but it does not necessarily result in a marked decrease of memory impairment.

Question 11

An older adult patient has fluctuating levels of awareness, anxiety, and appears to be picking things out of the air.The patient says, "I saw my granddaughter standing at the foot of the bed last night." The nurse should suspect which disorder?

Accepted Answer

Fluctuating levels of awareness, anxiety, and hallucinations are all symptoms of delirium. Dementia typically presents as a gradual decline in cognitive function, while schizophrenia and bipolar disorder may also have psychotic symptoms but do not necessarily involve the fluctuating mental status that is seen in delirium.

Question 12

A patient diagnosed with vascular dementia does not remember family members' names.The family insistently reorients the patient, and the patient becomes more agitated.What is the most likely reason for the patient's reaction?

Accepted Answer

Individuals with dementia may become overwhelmed and agitated when repeatedly reoriented to things they cannot remember. This response is not due to guilt, distraction, or reliving past chaos. It is important for caregivers to learn effective communication techniques and to avoid reinforcing the patient's stress and agitation.

Question 13

A nurse assesses a newly admitted patient with possible delirium.Which aspect of the history provides by family members contributes to confirmation of the diagnosis?

Accepted Answer

Sudden onset of confusion is a hallmark symptom of delirium, differentiating it from other cognitive disorders like dementia, which has a gradual onset.

Question 14

An older patient had a subtotal gastrectomy after being diagnosed with stomach cancer.What long-term mental health risk related to this procedure should the nurse discuss with the patient?

Accepted Answer

A subtotal gastrectomy can lead to vitamin B12 deficiency due to the loss of intrinsic factor production in the stomach, which is necessary for B12 absorption. Long-term B12 deficiency can lead to neurological issues, including dementia-like symptoms.

Question 15

A nurse gives anticipatory guidance to the family of a patient diagnosed with stage 2 Alzheimer disease (AD).Which problem common to that stage should be addressed?

Accepted Answer

Communication deficits are common in stage 2 of Alzheimer's disease, as the patient may struggle with finding the right words, speaking clearly, and understanding what is being said to them. It is important for the family to be aware of these challenges and to be patient and supportive in their communication with the patient. While the other problems listed may occur at later stages of the disease, they are less common in stage 2.

Question 16

An older adult patient diagnosed with delirium is anxious, agitated, and experiencing visual hallucinations.The nurse entering the room to assess vital signs should implement which intervention to best address this behavior?

Accepted Answer

Calmly announcing oneself, explaining what is going to happen, and using a gentle touch can help decrease anxiety and agitation in a patient with delirium. This approach helps to establish a trusting relationship with the patient, which can be helpful in managing their behavior. Limiting talking with the client may not be helpful, as it may increase their feelings of isolation and confusion. Asking the patient to identify place, person, and time may further agitate them if they are unable to do so. Turning on all lights in the room may increase misinterpretations of events and worsen the visual hallucinations.

Question 17

What is the nursing care priority for a patient diagnosed with stage 7 Alzheimer disease?

Accepted Answer

The nursing care priority for a patient diagnosed with stage 7 Alzheimer's disease is to ensure adequate nutrition and hydration as they may have difficulty swallowing and forget to eat or drink. This will prevent dehydration and malnutrition, which can lead to numerous health complications. While promoting self-care activities, supporting attempts to communicate, and preserving problem-solving abilities are all important aspects of care, none of them take precedence over addressing the patient's basic physiological needs.

Question 18

Effective management of a client diagnosed with Huntington disease is best demonstrated by which documentation made by the nurse?

Accepted Answer

Huntington disease primarily affects motor control and cognitive function, but respiratory complications can arise due to muscle weakness. Monitoring lung sounds and signs of dyspnea is crucial for effective management.

Question 19

What information should the nurse provide the family of a client diagnosed with normal-pressure hydrocephalus (NPH)?

Accepted Answer

The nurse should provide the family with information that NPH-related dementia is potentially reversible with surgical treatment. This information offers the family hope and encourages them to explore treatment options with their healthcare provider. Option A is incorrect since Pick disease is a distinct disorder from NPH. Option B is incorrect as there is treatment for NPH, which involves surgery to relieve pressure on the brain. Option C is incorrect since many clients with NPH may regain some of their cognitive abilities after the procedure.

Question 20

A newly admitted patient diagnosed with Alzheimer disease (AD) has demonstrated apraxia.The nurse should assist the patient with which activity?

Accepted Answer

Apraxia is the inability to perform a specific motor task despite intact motor function. Grooming and hygiene involve complex motor tasks such as brushing teeth, washing face, shaving, and combing hair. Patients with apraxia may have difficulty performing these activities independently, and therefore require assistance. Reading written material, word finding, and orientation are not specifically related to apraxia.

Quiz 28: Cognitive Disorders