Question 1

A nurse is caring for a patient who is confused,disoriented,and experiencing visual hallucinations.While preparing to provide personal care,the nurse should:

Accepted Answer

In these situations nurses should identify themselves each time they enter the room and give the patient simple explanations and directives.A patient with cognitive impairment cannot be expected to remember the nurse from visit to visit and will respond better to easily comprehended information.The nurse also should be prepared to repeat directions as often as necessary.

Question 2

A person who is the caregiver of a parent with early-to-middle-stage Alzheimer disease is concerned about possible episodes of incontinence.What strategy should the nurse suggest?

Accepted Answer

This measure will best protect patient dignity and preserve functional status at this time.Limiting fluid intake and the introduction of an indwelling catheter are not justified and could result in physical harm to the patient.While placing plastic protectors on the furniture may help prevent damage,the intervention has no impact on the prevention of incontinence.

Question 3

The goal for a patient with disturbed thought processes is,"The patient will:

Accepted Answer

Achieving optimum cognitive functioning relates directly to the problem of disturbed thought processes.The other options make appropriate short-term goals.

Question 4

A 72-year-old female patient has delirium secondary to anticholinergic medication toxicity.The nurse planning discharge care teaches the family to be alert for maladaptive cognitive symptoms because:

Accepted Answer

Slower metabolism and excretion of drugs predispose the elderly to toxic reactions marked by maladaptive cognitive responses.This is particularly true with anticholinergics and benzodiazepines.

Question 5

A nurse caring for a patient with Alzheimer disease can anticipate that the family will most likely need information about:

Accepted Answer

Acetylcholinesterase inhibitors are often prescribed to treat Alzheimer disease.These drugs allow greater concentration of acetylcholine in the brain,thereby improving cognitive function.

Question 6

A patient has sundown syndrome.The nurse can expect that the patient will:

Accepted Answer

When cognitive ability diminishes in the evening,the pattern is called sundown syndrome.Diminished cognitive ability may result in patient disorientation and agitation.

Question 7

A widowed patient tells a nurse that the door should be left unlocked because her husband will be coming home soon.Which response by the nurse would be most therapeutic?

Accepted Answer

An empathic response is always helpful,as is gentle,diplomatic reorientation.Abrupt confrontation with reality will increase anxiety,but implicitly agreeing that the spouse will come home fosters false hope.

Question 8

An individual is brought to the emergency room after family reports that the patient awoke confused and began "rambling and talking crazy" about 3 hours ago.The patient strikes out at the staff and shouts,"You're not going to kill me!" The most likely analysis of this behavior is:

Accepted Answer

Defining characteristics of sensory-perceptual alteration are present.For impaired environmental interpretational syndrome to be diagnosed,the confused state must have been present for 3 to 6 months.There is no reported history of a catastrophic event while the presence of the other assessment data makes fear associated with hospitalization a less likely reason for striking out at staff.

Question 9

A patient experiencing delirium secondary to drug toxicity is manifesting paranoid thinking and noisy,assaultive behavior and is currently pacing the room.The nurse's initial intervention is to:

Accepted Answer

Restraints may be ordered to protect the delirious patient from self-injury or from injuring others.Initially an attempt should be made to calm the patient by addressing him in a quiet,controlled manner.

Question 10

A nurse would attempt to reduce nighttime agitation for a patient with either delirium or dementia by:

Accepted Answer

A medium-intensity light will reduce shadows and reduce the agitation that comes with misinterpreted stimuli.A weaker-intensity light,such as the typical nightlight,may produce shadows.The snack may help minimize hunger and induce sleep but will have little effect on agitation,and the clock and family pictures may help with orientation only.

Question 11

Family members of a delirious elderly patient are very anxious and express their concerns about placing the patient in a nursing home.What information should serve as a basis for the nurse's reply?

Accepted Answer

Delirium is considered a reversible disorder when the cause has been discovered and treated.Most patients who are otherwise healthy can return to their former living arrangements.

Question 12

A 45-year-old patient shows marked cognitive impairment that has developed progressively over several months.A family member reports the patient's father had early-onset dementia.What research-based information can be given to the family in response to their concerns about the patient developing early-onset dementia?

Accepted Answer

The risk for development of Alzheimer disease (AD) is greater for relatives of people with the illness than it is for those with no family history of AD.An individual with one parent with early-onset AD has a 50% chance of developing it before the age of 55 years as well.Those offspring who do not inherit early-onset AD do not pass it on to their own children and presumably have the same risk of developing AD much later in life as does the general population.Down syndrome does appear to be a risk factor for early-onset AD

Question 13

An individual brought to the emergency room fights against the restraints and shouts incoherently.The history reveals that the patient was weak and confused on awakening this morning and soon began "rambling and talking crazy." A nurse notes that the patient's skin is flushed and dry.The priority nursing action is to:

Accepted Answer

The patient's history suggests a physiological basis for the cognitive disturbance.Vital signs will tell the nurse more about the patient's physical condition.

Question 14

A patient diagnosed with dementia associated with excessive alcohol use is shown a pencil,a nickel,and a safety pin and asked to repeat the names of each.Later when asked to identify these three items the patient is unable to do so.The nurse assesses this as:

Accepted Answer

Agnosia is difficulty recognizing well-known objects.

Question 15

Which intervention would likely be most useful when attempting to prevent or lessen the symptoms associated with sundown syndrome?

Accepted Answer

Sundown syndrome may be associated with having fewer orienting environmental stimuli,such as planned activities,meals,and contact with others.Frequent interactions with staff members will increase stimuli and provide opportunities for reorientation.

Question 16

An adult was brought to the emergency room.The patient's sensorium alternates between clouded and clear,and the patient becomes agitated both physically and verbally when approached.The patient's roommate states,"The patient was fine after getting up this morning but started talking crazy about 3 hours ago." The patient's cognitive impairment is most consistent with:

Accepted Answer

Delirium is the behavioral response to widespread disturbances in cerebral metabolism and usually represents a sudden decline from the previous level of functioning.It usually is considered a medical emergency.

Question 17

A patient diagnosed with dementia associated with excessive alcohol use tells a nurse,"Last week I had to take my baby to the hospital for major surgery.That's why I've been so nervous and needed to come here." The nurse is aware that the patient has never parented any children.The symptom described can be assessed as:

Accepted Answer

Confabulation is the process of making up a response to a question when one cannot remember the answer.It is a face-saving strategy that helps the individual deny memory loss.

Question 18

An individual being treated in the emergency room is found to have flushed,dry skin and sensorium that alternates between clouded and clear.A friend reveals the patient has not voided or ingested food or fluid in 18 hours.When the health care provider diagnoses fever of unknown origin,the plan is to make an effort to orally hydrate before attempting to start an IV line.The intervention most likely to be effective will be:

Accepted Answer

The nurse should assume or delegate responsibility for providing fluids hourly.The remaining options are unlikely to result in substantial intake.

Question 19

Which nursing diagnosis would be appropriate for a patient with Alzheimer disease?

Accepted Answer

The maladaptive cognitive responses of a patient with Alzheimer disease are associated with the presence of neuritic plaques,neurofibrillary tangles,and cortical atrophy.

Question 20

An individual was brought to the emergency room with impaired cognitive function.The patient's aggressive behavior and attempts to get out of bed present a safety issue.The nurse should first:

Accepted Answer

Reality orientation is generally helpful to patients with cognitive impairment.A patient who is misinterpreting reality should be reoriented by a nurse who uses a calm manner and soothing voice.Reorientation is the least restrictive way of addressing the behaviors.Restraints or holding the patient down would increase agitation; assigning staff to stay with the patient continuously is not appropriate as an initial intervention.

Quiz 22: Cognitive Responses and Organic Mental Disorders