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An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police took the person home, the spouse reported frequent wandering into neighbors' homes. Which stage of Alzheimer's disease is evident?
- A. 1 (mild)
- B. 2 (moderate)
- C. 3 (moderate to severe)
- D. 4 (late)
Correct Answer: B
Rationale: In stage 2 (moderate), deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. Hygiene may begin to deteriorate. Stage 3 (moderate to severe) finds the individual unable to identify familiar objects or people and needing direction for the simplest of tasks. In stage 4 (late), the ability to talk and walk is eventually lost, and stupor evolves.
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Goals and desired outcomes for an older adult patient experiencing delirium caused by fever and dehydration will focus on what?
- A. Returning to premorbid levels of function
- B. Identifying stressors negatively affecting self
- C. Demonstrating motor responses to noxious stimuli
- D. Exerting control over responses to perceptual distortions
Correct Answer: A
Rationale: The desired overall goal is that the patient with delirium will return to the level of functioning held before the development of delirium since the condition is usually temporary in nature. Demonstrating motor responses to noxious stimuli is an appropriate indicator for a patient whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a patient experiencing delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for the patient with sensorium problems related to delirium.
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 was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident?
- A. Aphasia
- B. Apraxia
- C. Agnosia
- D. Memory impairment
Correct Answer: C
Rationale: Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. No evidence of memory loss is revealed in this scenario.
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.
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.