Nokea
Two patients in a residential care facility are diagnosed with dementia. One shouts to the other, 'Move along, you're blocking the road.' The other patient turns, shakes a fist, and shouts, 'I know what you're up to; you're trying to steal my car.' What is the nurse's best action?
- A. Administer one dose of an antipsychotic medication to both patients.
- B. Reinforce reality. Say to the patients, 'Walk along in the hall. This is not a traffic intersection.'
- C. Separate and distract the patients. Take one to the day room and the other to an activities area.
- D. Step between the two patients and say, 'Please quiet down. We do not allow violence here.'
Correct Answer: C
Rationale: Separating and distracting prevents escalation from verbal to physical acting out. Neither patient loses self-esteem during this intervention. Medication is probably not necessary. Stepping between two angry, threatening patients is an unsafe action, and trying to reinforce reality during an angry outburst will probably not be successful when the patients are cognitively impaired.
You may also like to solve these questions
When used for treatment of patients diagnosed with Alzheimer's disease, which medication would be expected to antagonize N-methyl-D-aspartate (NMDA) channels rather than cholinesterase?
- A. Donepezil
- B. Rivastigmine
- C. Memantine
- D. Galantamine
Correct Answer: C
Rationale: Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterase inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimer's disease.
An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident?
- A. Aphasia
- B. Apraxia
- C. Agnosia
- D. Memory impairment
Correct Answer: C
Rationale: Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. No evidence of memory loss is revealed in this scenario.
An older adult patient in an intensive care unit is experiencing visual and auditory illusions. Which nursing intervention will be most helpful?
- A. Keep the room brightly lit at all times.
- B. Place personally meaningful objects in view.
- C. Place large clocks and calendars on the wall.
- D. Assess the patient's for use of glasses and hearing aids.
Correct Answer: D
Rationale: Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations.
A patient diagnosed with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members?
- A. Wear large name tags.
- B. Focus interaction on familiar topics.
- C. Frequently repeat the reorientation strategies.
- D. Strategically place large clocks and calendars.
Correct Answer: B
Rationale: Reorientation may seem like arguing to a patient experiencing cognitive deficits and increases the patient's anxiety. Validating, talking with the patient about familiar, meaningful things, and reminiscing give meaning to existence both for the patient and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and strategically placing large clocks and calendars are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable; patients with dementia sometimes become more agitated with reorientation.
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.