Nokea
Consider these health problems: Lewy body disease, Pick disease, and Parkinson's disease. Which term unifies these problems?
- A. Intoxication
- B. Dementia
- C. Delirium
- D. Amnesia
Correct Answer: B
Rationale: The listed health problems are all forms of dementia.
You may also like to solve these questions
What is the priority nursing need for a patient diagnosed with late-stage dementia?
- A. Promotion of self-care activities
- B. Meaningful verbal communication
- C. Maintenance of nutrition and hydration
- D. Prevention of the patient from wandering
Correct Answer: C
Rationale: In late-stage dementia, the patient has often forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the patient is to live. The patient is incapable of self-care, ambulation, or verbal communication.
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.
Which environmental adjustment should the nurse make for a patient experiencing delirium with perceptual alterations?
- A. Keep the patient by the nurse's desk while the patient is awake. Provide rest periods in a room with a television on.
- B. Light the room brightly, day and night. Awaken the patient hourly to assess mental status.
- C. Maintain soft lighting day and night. Keep a radio on low volume continuously.
- D. Provide a well-lit room without glare or shadows. Limit noise and stimulation.
Correct Answer: D
Rationale: A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient experiencing cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations.
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 patient diagnosed with moderate to severe Alzheimer's disease has a dressing and grooming self-care deficit. The nurse notes that the patient is wearing mismatched clothing and has poor personal hygiene. Which interventions should be included in the patient's plan of care?
- A. Provide clothing with elastic and hook-and-loop closures.
- B. Label clothing with the patient's name and name of the item.
- C. Administer antianxiety medication before bathing and dressing.
- D. Provide necessary items and direct the patient to proceed independently.
- E. If the patient resists, use distraction and then try again after a short interval.
Correct Answer: A,B,E
Rationale: Providing clothing with elastic and hook-and-loop closures facilitates patient independence. Labeling clothing with the patient's name and the name of the item maintains patient identity and dignity (and provides information if the patient has agnosia). When a patient resists, using distraction and trying again after a short interval are appropriate because patient moods are often labile; the patient may be willing to cooperate during a later opportunity. Providing the necessary items for grooming and directing the patient to proceed independently are inappropriate. Staff members are prepared to coach by giving step-by-step directions for each task as it occurs. Administering anxiolytic medication before bathing and dressing is inappropriate. This measure would result in unnecessary overmedication.