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During the change of shift report in the intensive care unit, the nurse learns that a client has developed signs of delirium over the past 8 hours. Which behavior documented in the nursing notes would be consistent with delirium?
- A. Unable to identify a water pitcher
- B. Unable to transfer to sitting position
- C. Difficulty with verbal expression
- D. Disoriented to person
Correct Answer: D
Rationale: Delirium is characterized by sudden onset and disorientation, such as to person, unlike dementia, which involves agnosia, apraxia, or aphasia.
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The grown daughter of a woman with Alzheimer's disease reports to the nurse that she is trying to keep her mother's condition from worsening by asking her questions whenever they are together. Which will be accomplished by this intervention?
- A. Decrease environmental misinterpretation
- B. Improve memory retention
- C. Increase frustration
- D. Slow the progress of the disease
Correct Answer: C
Rationale: Questioning clients with Alzheimer's about tasks they cannot perform increases frustration due to their progressive cognitive decline.
Which is the most effective intervention for clients with delirium?
- A. Giving detailed explanations
- B. Managing environmental stimuli
- C. Promoting rest with PRN medications
- D. Providing activities for distraction
Correct Answer: B
Rationale: Managing environmental stimuli reduces overstimulation, which is critical for clients with delirium.
The nurse is caring for a client with cognitive impairment. To determine whether the client is suffering from delirium or dementia, the nurse reviews the symptoms and course of each disorder.
- A. Rapid onset
- B. Progressive decline
- C. Long-term memory impairment
- D. Slurred speech
- E. Hallucinations
Correct Answer: A : Delirium, B: Dementia, C: Dementia, D: Delirium ,E: Delirium
Rationale: Delirium features rapid onset, slurred speech, and hallucinations, while dementia involves progressive decline and long-term memory impairment.
A new nurse has been working with clients with Alzheimer's disease for almost 6 months. During a staff meeting, the nurse expresses frustration because the same instructions have to be given to clients on a daily basis. The nurse states, 'I feel like all my work doesn't do them any good.' Which should the nurse's supervisor encourage the nurse to do?
- A. Cease giving instructions because the clients will not remember them anyway.
- B. Try to stay supportive and meet the clients' needs at the current moment.
- C. Seek counseling if personal feelings get in the way of client care.
- D. Consider transferring to a different client care specialty area.
Correct Answer: B
Rationale: Remaining supportive and focusing on current needs helps manage frustration and maintains client-centered care.
A nurse is educating a group of elderly community members about cognitive disorders. Which would the nurse include as a measure most likely to prevent Alzheimer's disease and other dementias?
- A. Crafts
- B. Cooking
- C. Watching television
- D. Reading
Correct Answer: D
Rationale: Reading and other brain-stimulating activities are associated with a reduced risk of Alzheimer's disease.