Nokea
The nurse is performing a health history with a client exhibiting signs of delirium. The nurse asks the client and family members about possible causes of the delirious state. Which would the nurse likely attribute as underlying causes for the client's delirium? Select all that apply.
- A. Recent alcohol use
- B. Dehydration
- C. Use of antihistamines
- D. Sleep disturbances
- E. Use of megadoses of vitamins
- F. Exposure to paint or gasoline
Correct Answer: A,B,C,D,F
Rationale: Delirium can be triggered by alcohol, dehydration, antihistamines, sleep disturbances, and exposure to toxins like paint or gasoline, but not typically by megadoses of vitamins.
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Which statement made by the nurse would be most appropriate to an 89-year-old patient who is confused but has no history of dementia and is hospitalized for an acute urinary tract infection?
- A. You are likely to become progressively more confused now.
- B. This should be just a temporary situation.
- C. Don't worry about it, everyone is confused when they are in the hospital.
- D. I know things are upsetting and confusing right now, but your confusion should clear as you get better.
Correct Answer: D
Rationale: This response validates the patient's feelings while providing reassurance that delirium from the infection is typically temporary.
The daughter of a client with dementia has been the primary caregiver for 5 months. The daughter expresses to the nurse, 'At times it is so overwhelming! I feel I do not have a life anymore!' Which is the most helpful response by the nurse?
- A. Are you saying you don't want to care for your mother anymore?
- B. I know it is really hard. It takes a lot of work and you are doing such a good job.
- C. Your mother really appreciates what you do for her. You are the best one to care for her.
- D. Here is the number of a caregivers' support group. How do you think you would feel talking with others in the same situation?
Correct Answer: D
Rationale: Offering a support group provides practical help and emotional validation for the caregiver's stress.
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.
Which are possible sources of frustrations for nurses caring for persons with dementia? Select all that apply.
- A. The clients do not retain explanations or instructions, so the nurse must repeat the same things continually.
- B. The nurse may get little or no positive response or feedback from clients with dementia.
- C. It can be difficult to remain positive and supportive to clients and family because the outcome is so bleak.
- D. It can be helpful for the nurse to talk to colleagues or even a counselor about personal feelings of depression and grief as the dementia progresses.
- E. The clients may seem not to hear or respond to anything the nurse does.
Correct Answer: A,B,C,E
Rationale: Repetition, lack of response, bleak outcomes, and non-responsiveness contribute to nurse frustration, while discussing feelings is a coping strategy, not a source of frustration.
The nursing supervisor in an extended care facility is managing the environment to best help the clients with dementia. Which should the nurse include in planning the living environment?
- A. Plan for the same caregivers to provide care to individuals as much as possible.
- B. Open the windows and doors to allow fresh air to circulate through the environment.
- C. Provide a buffet-style menu with many food choices.
- D. Assign peer-led exercise activities on a daily basis.
Correct Answer: A
Rationale: Consistent caregivers provide familiarity and reduce confusion in clients with dementia.