Nokea
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.
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Which assessment findings would the nurse expect in a patient experiencing delirium?
- A. Impaired level of consciousness
- B. Disorientation to place and time
- C. Wandering attention
- D. Apathy
- E. Agnosia
Correct Answer: A,B,C
Rationale: Disorientation to place, time, and person is an expected finding in delirium. Orientation to person (self) usually remains intact. Attention span is short, and difficulty focusing or shifting attention as directed is often noted. Patients with delirium commonly experience illusions and hallucinations. Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is associated with depression.
What is the priority nursing intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations?
- A. Avoidance of physical contact
- B. High level of sensory stimulation
- C. Careful observation and supervision
- D. Application of wrist and ankle restraints
Correct Answer: C
Rationale: Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient remains safe and free from injury. Physical contact during care cannot be avoided. Restraint is a last resort, and sensory stimulation should be reduced.
A patient experiencing fluctuating levels of awareness, confusion, and disturbed orientation shouts, 'Bugs are crawling on my legs! Get them off!' Which problem is the patient experiencing?
- A. Aphasia
- B. Dystonia
- C. Tactile hallucinations
- D. Mnemonic disturbance
Correct Answer: C
Rationale: The patient feels bugs crawling on both legs, although no sensory stimulus is actually present. This description coincides with the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium.
A patient diagnosed with stage 1 mild Alzheimer's disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time?
- A. Complicated grieving
- B. Impaired memory
- C. Self-care deficit
- D. Caregiver role strain
Correct Answer: B
Rationale: Memory impairment is present and expected in stage 1 mild Alzheimer's disease. Patients diagnosed with early Alzheimer's disease often have difficulty remembering names, so socialization is minimized. Data are not present to support the other diagnoses.
What is the priority nursing need for a patient diagnosed with late-stage dementia?
- A. Promotion of self-care activities
- B. Meaningful verbal communication
- C. Maintenance of nutrition and hydration
- D. Prevention of the patient from wandering
Correct Answer: C
Rationale: In late-stage dementia, the patient has often forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the patient is to live. The patient is incapable of self-care, ambulation, or verbal communication.