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A patient diagnosed with Alzheimer's disease wanders at night. Which action should the nurse recommend for a family to use in the home to enhance safety?
- A. Place throw rugs on tile or wooden floors.
- B. Place locks at the tops of doors.
- C. Encourage daytime napping.
- D. Obtain a bed with side rails.
Correct Answer: B
Rationale: Placing door locks at the top of the door makes it more difficult for the patient with dementia to unlock the door because the ability to look up and reach upward is diminished. All throw rugs should be removed to prevent falls. The patient will try to climb over side rails, increasing the risk for injury and falls. Day napping should be discouraged with the hope that the patient will sleep during the night.
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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 patient has progressive memory deficit associated with dementia. Which nursing intervention would best help the individual function in the environment?
- A. Assist the patient to perform simple tasks by giving step-by-step directions.
- B. Reduce frustration by performing activities of daily living for the patient.
- C. Stimulate intellectual function by discussing new topics with the patient.
- D. Promote the use of the patient's sense of humor by telling jokes.
Correct Answer: A
Rationale: Patients with a cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the patient is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the patient. Patients with cognitive deficits may lose their sense of humor and find jokes meaningless.
What is the priority nursing diagnosis for a patient experiencing fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?
- A. Bathing/hygiene self-care deficit related to altered cerebral function as evidenced by confusion and inability to perform personal hygiene tasks
- B. Risk for injury related to altered cerebral function, misperception of the environment, and unsteady gait
- C. Disturbed thought processes related to medication intoxication as evidenced by confusion, disorientation, and hallucinations
- D. Fear related to sensory perceptual alterations as evidenced by hiding from imagined ferocious dogs
Correct Answer: B
Rationale: The physical safety of the patient is the highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful; when the patient exercises poor judgment; and when the patient's sensorium is clouded. The other diagnoses may be concerns but are lower priorities.
Two patients in a residential care facility are diagnosed with dementia. One shouts to the other, 'Move along, you're blocking the road.' The other patient turns, shakes a fist, and shouts, 'I know what you're up to; you're trying to steal my car.' What is the nurse's best action?
- A. Administer one dose of an antipsychotic medication to both patients.
- B. Reinforce reality. Say to the patients, 'Walk along in the hall. This is not a traffic intersection.'
- C. Separate and distract the patients. Take one to the day room and the other to an activities area.
- D. Step between the two patients and say, 'Please quiet down. We do not allow violence here.'
Correct Answer: C
Rationale: Separating and distracting prevents escalation from verbal to physical acting out. Neither patient loses self-esteem during this intervention. Medication is probably not necessary. Stepping between two angry, threatening patients is an unsafe action, and trying to reinforce reality during an angry outburst will probably not be successful when the patients are cognitively impaired.
Which description of patient behavior best applies to a hallucination?
- A. Looking at shadows on a wall and says, 'I see scary faces'
- B. Stating, 'I feel bugs crawling on my legs and biting me'
- C. Becoming anxious when the nurse leaves his or her bedside
- D. Trying to hit the nurse when vital signs are taken
Correct Answer: B
Rationale: A hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The incorrect options are examples of behaviors that sometimes occur during delirium and are related to fluctuating levels of awareness and misinterpreted stimuli.