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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.
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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.
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.
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.
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.
An older adult diagnosed with moderate-stage Alzheimer's disease forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient's family?
- A. Labeling the bathroom door
- B. Taking the older adult to the bathroom hourly
- C. Placing the older adult in disposable adult diapers
- D. Making sure the older adult does not eat nonfood items
Correct Answer: A
Rationale: A patient with moderate Alzheimer's disease has memory loss that begins to interfere with activities. This patient may be able to use environmental cues such as labels on doors to compensate for memory loss. Regular toileting may be helpful, but a 2-hour schedule is often more reasonable. Placing the patient in disposable diapers is more appropriate as a later stage intervention. Making sure the patient does not eat nonfood items will be more relevant when the patient demonstrates hyperorality.