Question 1

A 72-year-old female patient is brought to the clinic by the patient's spouse,who reports that she 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?

Accepted Answer

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 self-image are helpful in assessing emotional status,but they are not as helpful in assessing mental state.

Question 2

A patient is being evaluated for Alzheimer's disease (AD).The nurse explains to the patient's adult children that

Accepted Answer

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.

Question 3

A 68-year-old 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?

Accepted Answer

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.

Question 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

Accepted Answer

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.

Question 5

Which action will help the nurse determine whether a new patient's confusion is caused by dementia or delirium?

Accepted Answer

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.

Question 6

A 71-year-old 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?

Accepted Answer

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.

Question 7

After reviewing the health record shown in the accompanying figure for a patient who has multiple risk factors for Alzheimer's disease,which topic will be most important for the nurse to discuss with the patient?

Accepted Answer

Tobacco use is a modifiable risk factor for Alzheimer's disease.The patient will not be able to modify the increased risk associated with family history of Alzheimer's disease and past head injury.While the total cholesterol is borderline high,the high HDL indicates that no change is needed in cholesterol management.

Question 8

The nurse is administering a mental status examination to a 48-year-old patient who has hypertension.The nurse suspects depression when the patient responds to the nurse's questions with

Accepted Answer

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.

Question 9

Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia?

Accepted Answer

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.

Question 10

The spouse of a 67-year-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)?

Accepted Answer

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.

Question 11

After change-of-shift report on the Alzheimer's disease/dementia unit,which patient will the nurse assess first?

Accepted Answer

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.

Question 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?

Accepted Answer

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.

Question 13

A 68-year-old patient is diagnosed with moderate dementia after multiple strokes.During assessment of the patient,the nurse would expect to find

Accepted Answer

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.

Question 14

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

Accepted Answer

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.

Question 15

Which hospitalized patient will the nurse assign to the room closest to the nurses' station?

Accepted Answer

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.

Question 16

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?

Accepted Answer

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.

Question 17

The nurse's initial action for a patient with moderate dementia who develops increased restlessness and agitation should be to

Accepted Answer

Increased motor activity in a patient with dementia is frequently the patient's only way of responding to factors like 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.

Question 18

Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had an appendectomy 2 days ago?

Accepted Answer

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.

Question 19

A 56-year-old patient in the outpatient clinic is diagnosed with mild cognitive impairment (MCI).Which action will the nurse include in the plan of care?

Accepted Answer

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.

Question 20

When administering the Mini-Cog exam to a patient with possible Alzheimer's disease,which action will the nurse take?

Accepted Answer

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.

Quiz 56: Nursing Management: Delirium,depression and Dementia