Question 1

A nurse is gathering information from the family of a patient who is experiencing confusion.What important question should the nurse ask the family?&#10;A) &#34;Are you sure she is confused? Maybe she just didn't hear what you were saying.&#34;&#10;B) &#34;When did you first think she might be confused? Tell me exactly what happened.&#34;&#10;C) &#34;Did something bad happen to her during her childhood?&#34;&#10;D) &#34;How can you say she is confused? She knows who she is.&#34;

Accepted Answer

This question is open-ended and allows the family to give detailed information about when they first noticed the confusion, what specific symptoms the patient is experiencing, and any other relevant history or events. It also shows the nurse's interest in learning more about the patient's condition. A, C, and D are inappropriate as they either challenge or dismiss the family's concerns or are not relevant to the patient's current condition.

Question 2

Which characteristics are most likely to be present in the patient with dementia?&#10;A) Forgets things relatively quickly and is usually unable to learn new things&#10;B) Can remember new tasks but will forget any previously taught tasks&#10;C) Cannot learn new information but will probably remember anything you ask about the past&#10;D) Responds well to reality orientation and needs to have a flexible schedule

Accepted Answer

The characteristic of forgetting things relatively quickly and being unable to learn new things is a common symptom of dementia. While individuals with dementia may have some moments of clarity and memory of the past, their ability to retain new information and learn new things is usually significantly impaired. Choices B and C are not typical of dementia, as the ability to remember new tasks or old information varies widely depending on the individual and stage of the disease. Choice D is also not necessarily true, as some individuals with dementia may respond well to reality orientation, while others may not benefit from it. A flexible schedule may be helpful for some individuals with dementia, but it is not a defining characteristic of the disease.

Question 3

What are the adaptations to interventions that the Cognitive Developmental Approach (CDA)to caring for patients with dementia designed to achieve?&#10;A) Increase cognitive abilities.&#10;B) Adapt environment to patient.&#10;C) Offer a wide variety of choices.&#10;D) Abolish irrational fears.

Accepted Answer

The Cognitive Developmental Approach (CDA) aims to adapt the environment to the patient with dementia, as individuals with dementia may struggle with their surroundings and require a supportive environment to thrive. The approach does not necessarily focus on increasing cognitive abilities or abolishing irrational fears, although offering a variety of choices can be a helpful strategy within the overall approach.

Question 4

While a nurse is dressing a patient who has dementia as a result of Huntington disease, the patient states, "I don't want to wear clothes today" and begins to resist help putting on her clothes.What is the nurse's most appropriate action?

A) Tell the patient that she must wear clothes or she cannot see her family later.
B) Get another nurse to help her force the patient to get dressed.
C) Talk to the patient about her family coming this afternoon and continue to assist the patient gently with dressing.
D) Let the patient go without clothes but make her stay in her room.

Accepted Answer

It is important to respect the patient's autonomy and not force her to wear clothes if she does not want to. Instead, the nurse should gently remind the patient about her family visiting and continue to assist her with dressing in a respectful manner. It is not appropriate to threaten or force the patient, or to leave her without clothes and isolate her in her room.

Question 5

A nurse is assessing a patient for the possibility of confusion.What two major types of confusion should the nurse be aware of to appropriately assess this patient?&#10;A) Acute and chronic senility&#10;B) Temporary and permanent confusion&#10;C) Delirium and dementia&#10;D) Senility and senile dementia

Accepted Answer

Delirium and dementia are the two major types of confusion that a nurse should be aware of. Delirium is an acute onset of confusion that can be caused by a medical condition or medication side effect. Dementia, on the other hand, is a chronic, progressive decline in cognitive function that can be caused by degenerative brain diseases such as Alzheimer's. It is important for the nurse to differentiate between the two in order to provide appropriate care and treatment.

Question 6

A patient has been admitted with a diagnosis of confusion.The physician's admission note states that he wants to assess for delirium versus dementia.What should the nurse be aware that the main differences include?

A) Whereas delirium usually lasts several years, dementia lasts only a few days.
B) Whereas delirium usually has sudden onset and is reversible, dementia is chronic and irreversible.
C) Whereas dementia is usually caused by medications, delirium is not.
D) Whereas dementia is easily treated with reality orientation, delirium is not.

Accepted Answer

The main differences between delirium and dementia include that delirium usually has a sudden onset and is reversible, while dementia is chronic and irreversible. Delirium may also be caused by medications, whereas dementia is not easily treated with reality orientation. The other options presented are incorrect.

Question 7

A nurse in a long-term care facility is taking patients to the dining room for lunch.She asks the patient who has been diagnosed with delirium if she is ready to go eat lunch.The patient does not respond.What should be the nurse's next action?

A) Take the patient by the arm and lead her to the dining room.
B) Assist the patient to bed and bring her lunch to her.
C) Tell the patient that she can go to the dining room whenever she gets hungry.
D) Ask the patient again if she is ready to go eat lunch.

Accepted Answer

In cases of delirium, patients may have difficulty processing information and responding appropriately. Repeating the question can give the patient another opportunity to understand and respond, and it's a non-invasive, patient-centered approach.

Question 8

A patient with delirium repeatedly cries out for her husband.What is the most appropriate initial nursing intervention?&#10;A) Administer Haldol as ordered.&#10;B) Apply restraints so that the patient will not harm herself.&#10;C) Calmly tell the patient that she is in the hospital and that her husband is not there.&#10;D) Call the husband and tell him that he needs to come and stay with his wife.

Accepted Answer

The nurse's initial intervention should aim to address the patient's distress and confusion. Calmly telling the patient that she is in the hospital and that her husband is not there can help to ground her in reality and reduce her anxiety. Administering medication or applying restraints should only be done as a last resort and under the guidance of a healthcare provider. Calling the husband may not be effective in immediately addressing the patient's distress and may not be feasible if the husband is not available or if the patient has difficulty communicating over the phone due to her delirious state.

Question 9

The family of a patient with Alzheimer disease asks the nurse, &#34;When will my mother quit being so confused?&#34; On what information regarding dementia should the nurse base a response?&#10;A) It is a short-term confusional state that is typically reversible.&#10;B) It is a state of confusion caused primarily by medications.&#10;C) It is a state of confusion that usually begins abruptly and lasts a short period.&#10;D) It is a syndrome that is chronic and irreversible.

Accepted Answer

Dementia, including Alzheimer's disease, is a chronic and irreversible syndrome characterized by progressive cognitive decline and impaired ability to perform daily activities. It is not a short-term or reversible confusional state, nor is it primarily caused by medications. The onset may be gradual or abrupt, but the symptoms will continue to progress over time.

Question 10

A nurse is assessing a patient for delirium versus dementia.What should the nurse expect the patient with dementia to display?&#10;A) Intermittent fear affect&#10;B) Perplexity affect&#10;C) Bewilderment affect&#10;D) Flat affect

Accepted Answer

Patients with dementia often display a flat affect, meaning they show reduced emotional expressiveness, react less to emotional stimuli, and may appear emotionally dull or indifferent. This is in contrast to the fluctuating symptoms and emotional states often seen in delirium.

Question 11

A patient is displaying confusion, which began very suddenly and lasted less than 1 week.What should the nurse suspect is present?&#10;A) Dementia&#10;B) Delirium&#10;C) Symptoms of Huntington disease&#10;D) Senile dementia

Accepted Answer

The answer of A patient is displaying confusion, which began...

Question 12

A nurse has found a patient with delirium in other patients' rooms several times.What is the best action by the nurse?&#10;A) Firmly tell the patient that he must stay out of other patients' rooms and tell him to return to his room.&#10;B) Take him back to his room and put him in bed with the side rails up.&#10;C) Take him to the nurses' station and let him visit for a while.&#10;D) Administer a dose of lorazepam (Ativan)as ordered.

Accepted Answer

The answer of A nurse has found a patient with...

Question 13

What initial nursing action should be implemented when assisting a patient with dementia to dress?&#10;A) Hand the patient her clothes and ask her to put them on.&#10;B) Hand the patient each article of clothing separately and ask her to put it on.&#10;C) Assist her with each article, giving specific instructions such as, &#34;Put your arm in this hole.&#34;&#10;D) Put the patient's clothes on without assistance from the patient.

Accepted Answer

The answer of What initial nursing action should be implemented...

Question 14

A nurse is taking a patient who has Alzheimer disease to the bathing room for a tub bath.The patient states, "Please don't make me take a bath today.I am so afraid that I will be washed down the drain." What is the nurse's best response?

A) "Don't be silly; there's no way you would fit in the drain."
B) "I am your nurse, and I will stay with you, so you shouldn't be afraid of your bath."
C) "Let's go back to your room, and I will bathe you there."
D) "Today is your day for a bath."

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Accepted Answer

The answer of A nurse is taking a patient who...

Question 15

A patient asks a nurse what causes dementia.What two most prevalent types of dementia should the nurse consider before responding?&#10;A) Pick disease and Huntington disease&#10;B) Alzheimer disease and vascular dementia&#10;C) Creutzfeldt-Jakob disease and Pick disease&#10;D) Vascular dementia and Huntington disease

Accepted Answer

The answer of A patient asks a nurse what causes...

Question 16

A nurse is planning for the nutritional needs of a patient with Alzheimer disease.What is the best plan to have the dietary department provide?&#10;A) Pureed diet to be fed with a syringe&#10;B) Foods that the patient can cut up to keep busy and not lose interest in eating&#10;C) Finger foods several times a day&#10;D) High-protein liquid diet

Accepted Answer

The answer of A nurse is planning for the nutritional...

Question 17

The family of a patient with dementia expresses concern to the nurse about the patient wandering at night.They are afraid that the patient might get up while they are sleeping and go outside.What is the best advice for the nurse to provide?

A) Apply a vest restraint at night.
B) Perform constant reality orientation.
C) Learn some behavior modification techniques.
D) Put new locks on the outside doors in new places.

Accepted Answer

The answer of The family of a patient with dementia...

Question 18

A nurse is admitting a patient who has been diagnosed as having confusion.What is the most important observation that the nurse should make regarding this patient?&#10;A) Eating, drinking, and sleeping patterns&#10;B) Behavior, orientation, memory, and sleeping habits&#10;C) Urinary and bowel elimination habits&#10;D) Talking, walking, and sleeping patterns

Accepted Answer

The answer of A nurse is admitting a patient who...

Question 19

When admitting a patient who has recently become confused, the nurse asks the family for a list of all the medications that the patient is currently taking.Which medication identified by the family should the nurse be aware could be causing confusion?

A) Amoxicillin
B) Acetaminophen
C) Furosemide
D) Digoxin

Accepted Answer

The answer of When admitting a patient who has recently...

Question 20

Reality orientation is helpful for some patients with confusion.What patient diagnosis is most appropriate for the nurse to implement this technique?&#10;A) Organic brain syndrome&#10;B) Senile dementia&#10;C) Senility&#10;D) Acute confusional state (delirium)

Accepted Answer

The answer of Reality orientation is helpful for some patients...

Question 21

An 80-year-old patient with delirium related to high fever is hallucinating about large animals being in the room.What is the most reassuring nursing response to this patient?&#10;A) &#34;Yes, the animals are in here, but they are sound asleep.&#34;&#10;B) &#34;I'm going to turn out the lights so you won't have to look at the animals.&#34;&#10;C) &#34;You are in the hospital.There are no animals in this room.&#34;&#10;D) &#34;The hospital does not allow animals in the room.&#34;

Accepted Answer

The answer of An 80-year-old patient with delirium related to...

Question 22

A nurse caring for a patient with dementia notices that the patient stays awake most of the night.What is the nurse's most appropriate action?&#10;A) Give a prescribed sleeping medication.&#10;B) Tell the patient that it is nighttime and that she must go to sleep.&#10;C) Check the patient's record to see whether she is sleeping during the day.&#10;D) Put the patient to bed and put the side rails up.

Accepted Answer

The answer of A nurse caring for a patient with...

Question 23

A patient asks a nurse, &#34;My doctor says I get confused sometimes because I have vascular dementia.What caused me to have that?&#34; What is the most appropriate response by the nurse?&#10;A) &#34;It is usually caused from damage to brain cells because of inadequate blood supply, like a small stroke.&#34;&#10;B) &#34;It is probably just some abnormal electrical activity in your brain.&#34;&#10;C) &#34;You probably have a brain tumor.&#34;&#10;D) &#34;I'm sure he will explain it to you later.&#34;

Accepted Answer

The answer of A patient asks a nurse, &#34;My doctor...

Question 24

A nurse is preparing a room for a patient being transferred from the emergency department with a diagnosis of delirium.What should the nurse ensure in regard to the room?&#10;A) Brightly lit&#10;B) Shared by another patient&#10;C) Visible from the nurses' station&#10;D) Dark and quiet

Accepted Answer

The answer of A nurse is preparing a room for...

Question 25

What should nursing care focus on to best support a patient with mild cognitive impairment (MCI)?&#10;A) Reorienting the patient to the physical environment&#10;B) Developing strategies to improve memory&#10;C) Assisting with dressing and eating&#10;D) Establishing toileting schedules

Accepted Answer

The answer of What should nursing care focus on to...

Question 26

What are believed to be causes of Alzheimer disease? (Select all that apply.)&#10;A)Amyloid deposits in the brain&#10;B)Excess of acetylcholine&#10;C)Neurofibrillary tangles&#10;D)Infiltration of Lewy bodies&#10;E)Series of small strokes

Accepted Answer

The answer of What are believed to be causes of...

Question 27

An 80-year-old woman who has Alzheimer disease is restless, wanders during mealtimes, and will not sit down to eat.The nurse assisting with writing the care plan prioritizes the following interventions for the goal: The patient will eat at least 25% of each meal.______ (Prioritize the options in sequence, from the most therapeutic to the least therapeutic.Do not separate answers with a space or punctuation.Example: ABCD.)

A)Place her in a chair with a vest restraint.
B)Assign a nursing assistant (NA)to feed her.
C)Give her a high-protein drink in a small cup to carry with her.
D)Offer peanut butter crackers as she passes by.
E)Leave her alone.She will eat when she is hungry.

Accepted Answer

The answer of An 80-year-old woman who has Alzheimer disease...

Question 28

A nurse is discussing home care of a patient with dementia with the patient's family.What should the nurse advise the family do to prevent the patient from wandering?&#10;A) Apply a vest restraint to keep the patient in bed or in a chair.&#10;B) Put locks on any doors that it would be dangerous for the patient to open (e.g., outside doors, medicine cabinet).&#10;C) Have someone remind the patient at least every 2 hours that he or she must not go outside by him or herself.&#10;D) Set up a reward system for the times the patient stays where the family has requested.

Accepted Answer

The answer of A nurse is discussing home care of...

Question 29

When a normally oriented 87-year-old resident in a long-term care facility exhibits acute confusion, the nurse should first assess for a(n)______.

Accepted Answer

The answer of When a normally oriented 87-year-old resident in...

Deck 13: Delirium and Dementia