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?

Accepted Answer

Loss of both recent and long-term memory is characteristic of middle dementia. Clients with dementia have frequent nighttime awakening. Dementia is progressive, and the client's ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia.

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?

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 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?

Accepted Answer

Increased motor activity in a client with dementia is frequently the client's only way of responding to factors like pain, so the nurse's initial action should be to assess the client 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 client with moderate dementia. Assigning a nursing assistant to stay with the client also may be necessary, but any physical changes that may be causing the agitation should be addressed first.

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?

Accepted Answer

Clients at risk for problems with safety require close supervision. Placing the client near the nurse's station will allow nursing staff to observe the client more closely. The use of "why" questions is frustrating for clients with AD because they are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the client's short-term memory loss, reorientation will not help prevent wandering behaviour. Because the client had wandering behaviour at home, familiar objects will not prevent wandering.

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?

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 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)?

Accepted Answer

Ongoing monitoring is recommended for clients with MCI. If mild cognitive impairment (MCI) is diagnosed, annual monitoring of symptoms and functioning is recommended.
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 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?

Accepted Answer

Pneumonia is a common complication in clients with DLB. They are not at an increased risk of stroke, MI, or urinary tract infection related to the DLB.

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?

Accepted Answer

Answers such as "I don't know" are more typical of depression. The response "Who are those people over there?" is more typical of the distraction seen in a client with delirium. The remaining two answers are more typical of a client with dementia.

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?

Accepted Answer

Rivastigmine is a cholinesterase inhibitor and is used to treat decreased memory and cognition. Sertraline and citalopram are selective serotonin reuptake inhibitors and are used to treat depression. Risperidone is an atypical antipsychotic medication and is not used to treat memory and cognition problems.

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?

Accepted Answer

The diagnosis of AD is one of exclusion. Age is the most important risk factor for development of AD. Drugs can slow the deterioration but do not dramatically 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 an AD diagnosis.

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)?

Accepted Answer

Consistent assignment of nursing staff, frequent reassurance, and orientation to place and time may reduce anxiety and prevent behavioural symptoms. In late-stage AD, the client will not remember events from the past. Reorientation to time and place will not be helpful to the client with late-stage AD, and the client will not be able to read.

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.)

Accepted Answer

The stress of being a caregiver can be managed with a multicomponent approach. This includes respite care, learning ways to manage challenging behaviours, and further assessment of what the spouse may already have considered. The client 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 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?

Accepted Answer

The priority goal is to protect the client from harm, and a staff member will be most experienced in providing safe care. Visits by family members are helpful in reorienting the client, but families should not be responsible for protecting clients from injury.
Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have multiple adverse effects. Restraints are sometimes used but tend to increase agitation and disorientation.

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?

Accepted Answer

The most likely cause of sundowning is a disruption in circadian rhythms and keeping the client active and in daylight will help to re-establish a more normal circadian pattern.
Moving the client to a different room might increase confusion. Taking a nap will interfere with nighttime sleep. Hourly orientation will not be helpful in a client with memory difficulties.

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?

Accepted Answer

The client 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 client with severe dementia, who would have difficulty with swallowing, self-care, and immobility.

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?

Accepted Answer

Because the client 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 client takes the medications.

Quiz 62: Nursing Management Delirium