Nokea
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.
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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.
A nurse should anticipate that which symptoms of Alzheimer's disease will become apparent as the disease progresses from stage 3, moderate to severe to stage 4, late stage?
- A. Agraphia
- B. Hyperorality
- C. Fine motor tremors
- D. Hypermetamorphosis
- E. Improvement of memory
Correct Answer: A,B,D
Rationale: The memories of patients with Alzheimer's disease continue to deteriorate. These patients demonstrate the inability to read or write (agraphia), the need to put everything into the mouth (hyperorality), and the need to touch everything (hypermetamorphosis). Fine motor tremors are associated with alcohol withdrawal delirium, not dementia. Memory does not improve.
A patient experiencing fluctuating levels of awareness, confusion, and disturbed orientation shouts, 'Bugs are crawling on my legs! Get them off!' Which problem is the patient experiencing?
- A. Aphasia
- B. Dystonia
- C. Tactile hallucinations
- D. Mnemonic disturbance
Correct Answer: C
Rationale: The patient feels bugs crawling on both legs, although no sensory stimulus is actually present. This description coincides with the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium.
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.
A patient diagnosed with stage 2 moderate Alzheimer's disease calls the police saying, 'An intruder is in my home.' Police investigate and discover the patient misinterpreted a reflection in the mirror as an intruder. This phenomenon can be characterized using which term?
- A. Hyperorality
- B. Aphasia
- C. Apraxia
- D. Agnosia
Correct Answer: D
Rationale: Agnosia is the inability to recognize familiar objects, parts of one's body, or one's own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movements, such as being unable to dress.