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What is the priority nursing need for a patient diagnosed with late-stage dementia?
- A. Promotion of self-care activities
- B. Meaningful verbal communication
- C. Maintenance of nutrition and hydration
- D. Prevention of the patient from wandering
Correct Answer: C
Rationale: In late-stage dementia, the patient has often forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the patient is to live. The patient is incapable of self-care, ambulation, or verbal communication.
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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.
An older adult takes digoxin and hydrochlorothiazide daily, as well as lorazepam as needed for anxiety. Over 2 days, this adult developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of which adverse reaction to the medication therapy?
- A. Delirium
- B. Dementia
- C. Amnestic syndrome
- D. Alzheimer's disease
Correct Answer: A
Rationale: Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer's disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems.
Which environmental adjustment should the nurse make for a patient experiencing delirium with perceptual alterations?
- A. Keep the patient by the nurse's desk while the patient is awake. Provide rest periods in a room with a television on.
- B. Light the room brightly, day and night. Awaken the patient hourly to assess mental status.
- C. Maintain soft lighting day and night. Keep a radio on low volume continuously.
- D. Provide a well-lit room without glare or shadows. Limit noise and stimulation.
Correct Answer: D
Rationale: A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient experiencing cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations.
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.
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.