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After teaching a group of nursing students about confusion and how it differs from dementia, the instructor determines that the teaching was successful when the students identify which of the following about delirium?
- A. The onset occurred suddenly.
- B. Memory is significantly impaired.
- C. Sensory impairment occurs.
- D. Environmental changes are needed for safety.
Correct Answer: A,C
Rationale: Delirium occurs suddenly, affects the senses, and is reversible when the cause is found. In contrast, dementia occurs slowly, affects memory and judgment, and is not reversible, often requiring a change in the environment to maintain safety.
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After teaching the caregiver of a client prescribed transdermal rivastigmine, the nurse determines that the teaching was successful when the caregiver states which of the following?
- A. I'll apply a new patch every other day.
- B. The patch should be placed on a hairless area.
- C. I'll make sure to put the patch where he can see it.
- D. I can use the same spot once or twice a week.
Correct Answer: B
Rationale: Rivastigmine patches are changed on a daily basis and rotated to a clean, dry, and hairless area. Because the patient is experiencing dementia, the site for application should be where the patient is not able to pick at or remove the patch. The upper or lower portions of the back are recommended for patch administration. Because the same site should not be used more than once every 2 weeks, the caregiver should be instructed to make a chart of the back and indicate where patches have been applied during the last 14 days.
A client with AD receiving a cholinesterase inhibitor has a nursing diagnosis of Imbalanced Nutrition: Less Than Body Requirements. Which of the following would be most appropriate?
- A. Provide nutritious meals three times a day.
- B. Give foods that have the same consistency.
- C. Encourage careful chewing.
- D. Encourage visitors during mealtime.
Correct Answer: C
Rationale: The nurse should encourage chewing action when feeding. The nurse need not provide nutritious meals three times a day; instead, frequent small nutritious meals would be more beneficial. Offering foods of different consistency and flavor is important in case the patient can handle one form better than another. The nurse should not encourage visitors during mealtime; mealtime should be simple and calm.
After teaching a group of nursing students about cholinesterase inhibitors, the instructor determines that additional teaching is needed when the students identify which drug as an example?
- A. Rivastigmine
- B. Donepezil
- C. Memantine
- D. Galantamine
Correct Answer: C
Rationale: Memantine is an example of an NMDA receptor antagonist. Rivastigmine, donepezil, and galantamine are cholinesterase inhibitors.
For a client who is receiving a cholinesterase inhibitor, which of the following can the nurse recommend to the client's caregiver to decrease the client's risk for injury?
- A. Observe frequent drug holidays.
- B. Encourage the use of assistive devices.
- C. Keep the bed in a low position.
- D. Use night lights.
- E. Decrease drug dose if mobility worsens.
Correct Answer: B,C,D
Rationale: To minimize the client's risk for injury, the nurse should encourage using assistive devices and keeping the bed in a low position, using night lights, and frequent monitoring by the caregiver.
A nurse is preparing to administer rivastigmine oral solution. The nurse decides to mix it in a small amount of which of the following?
- A. Water
- B. Coffee
- C. Soda
- D. Tea
- E. Fruit juice
Correct Answer: A,C,E
Rationale: A nurse administering rivastigmine (Exelon) oral solution can give the solution directly to the client or mix it in a small amount of water, cold fruit juice, or soda.