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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.
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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.
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.
A patient experiencing fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, 'Someone get these bugs off me.' What is the nurse's best response?
- A. There are no bugs on your legs. Your imagination is playing tricks on you.'
- B. Try to relax. The crawling sensation will go away sooner if you can relax.'
- C. Don't worry. I will have someone stay here and brush off the bugs for you.'
- D. I don't see any bugs, but I know you are frightened so I will stay with you.'
Correct Answer: D
Rationale: When hallucinations are present, the nurse should acknowledge the patient's feelings and state the nurse's perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patient's perception without offering help does not emotionally support the patient. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions.
Which condition is characterized with apolipoprotein E (apoE) malfunction, neuritic plaques, neurofibrillary tangles, granulovascular degeneration, and brain atrophy?
- A. Alzheimer's disease
- B. Wernicke encephalopathy
- C. Central anticholinergic syndrome
- D. Acquired immunodeficiency syndrome (AIDS)-related dementia
Correct Answer: A
Rationale: The problems are all aspects of the pathophysiological characteristics of Alzheimer's disease. These characteristics are not noted in any of the other options.
Which nursing intervention is appropriate to use for patients diagnosed with either delirium or dementia?
- A. Speak in a loud, firm voice.
- B. Touch the patient before speaking.
- C. Reintroduce the health care worker at each contact.
- D. When the patient becomes aggressive, use physical restraint instead of medication.
Correct Answer: C
Rationale: Short-term memory is often impaired in patients with delirium and dementia. Reorientation to staff is often necessary with each contact to minimize misperceptions, reduce anxiety level, and secure cooperation. Loud voices may be frightening or sound angry. Speaking before touching prevents the patient from feeling threatened. Physical restraint is not appropriate; the least restrictive measure should be used.