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A hospitalized patient experiencing delirium misinterprets reality and a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios?
- A. Patient will remain safe in the environment.
- B. Patient will participate actively in self-care.
- C. Patient will communicate verbally.
- D. Patient will acknowledge reality.
Correct Answer: A
Rationale: Risk for injury is the nurse's priority concern in both scenarios. Safety maintenance is the desired outcome. The other outcomes may not be realistic.
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Which condition is characterized with apolipoprotein E (apoE) malfunction, neuritic plaques, neurofibrillary tangles, granulovascular degeneration, and brain atrophy?
- A. Alzheimer's disease
- B. Wernicke encephalopathy
- C. Central anticholinergic syndrome
- D. Acquired immunodeficiency syndrome (AIDS)-related dementia
Correct Answer: A
Rationale: The problems are all aspects of the pathophysiological characteristics of Alzheimer's disease. These characteristics are not noted in any of the other options.
A nurse should anticipate that which symptoms of Alzheimer's disease will become apparent as the disease progresses from stage 3, moderate to severe to stage 4, late stage?
- A. Agraphia
- B. Hyperorality
- C. Fine motor tremors
- D. Hypermetamorphosis
- E. Improvement of memory
Correct Answer: A,B,D
Rationale: The memories of patients with Alzheimer's disease continue to deteriorate. These patients demonstrate the inability to read or write (agraphia), the need to put everything into the mouth (hyperorality), and the need to touch everything (hypermetamorphosis). Fine motor tremors are associated with alcohol withdrawal delirium, not dementia. Memory does not improve.
A patient experiencing fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, 'Someone get these bugs off me.' What is the nurse's best response?
- A. There are no bugs on your legs. Your imagination is playing tricks on you.'
- B. Try to relax. The crawling sensation will go away sooner if you can relax.'
- C. Don't worry. I will have someone stay here and brush off the bugs for you.'
- D. I don't see any bugs, but I know you are frightened so I will stay with you.'
Correct Answer: D
Rationale: When hallucinations are present, the nurse should acknowledge the patient's feelings and state the nurse's perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patient's perception without offering help does not emotionally support the patient. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions.
Which nursing intervention is appropriate to use for patients diagnosed with either delirium or dementia?
- A. Speak in a loud, firm voice.
- B. Touch the patient before speaking.
- C. Reintroduce the health care worker at each contact.
- D. When the patient becomes aggressive, use physical restraint instead of medication.
Correct Answer: C
Rationale: Short-term memory is often impaired in patients with delirium and dementia. Reorientation to staff is often necessary with each contact to minimize misperceptions, reduce anxiety level, and secure cooperation. Loud voices may be frightening or sound angry. Speaking before touching prevents the patient from feeling threatened. Physical restraint is not appropriate; the least restrictive measure should be used.
An older adult patient in an intensive care unit is experiencing visual and auditory illusions. Which nursing intervention will be most helpful?
- A. Keep the room brightly lit at all times.
- B. Place personally meaningful objects in view.
- C. Place large clocks and calendars on the wall.
- D. Assess the patient's for use of glasses and hearing aids.
Correct Answer: D
Rationale: Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations.