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A patient diagnosed with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members?
- A. Wear large name tags.
- B. Focus interaction on familiar topics.
- C. Frequently repeat the reorientation strategies.
- D. Strategically place large clocks and calendars.
Correct Answer: B
Rationale: Reorientation may seem like arguing to a patient experiencing cognitive deficits and increases the patient's anxiety. Validating, talking with the patient about familiar, meaningful things, and reminiscing give meaning to existence both for the patient and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and strategically placing large clocks and calendars are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable; patients with dementia sometimes become more agitated with reorientation.
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When used for treatment of patients diagnosed with Alzheimer's disease, which medication would be expected to antagonize N-methyl-D-aspartate (NMDA) channels rather than cholinesterase?
- A. Donepezil
- B. Rivastigmine
- C. Memantine
- D. Galantamine
Correct Answer: C
Rationale: Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterase inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimer's disease.
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.
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.
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.
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.