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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.
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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.
During morning care, an assistive personnel asks a patient diagnosed with dementia, 'How was your night?' The patient replies, 'It was lovely. I went out to dinner and a movie with my friend.' Which term applies to the patient's response?
- A. Sundown syndrome
- B. Confabulation
- C. Perseveration
- D. Delirium
Correct Answer: B
Rationale: Confabulation is the making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The patient's response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario.
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.
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.