Nokea
Which assessment findings would the nurse expect in a patient experiencing delirium?
- A. Impaired level of consciousness
- B. Disorientation to place and time
- C. Wandering attention
- D. Apathy
- E. Agnosia
Correct Answer: A,B,C
Rationale: Disorientation to place, time, and person is an expected finding in delirium. Orientation to person (self) usually remains intact. Attention span is short, and difficulty focusing or shifting attention as directed is often noted. Patients with delirium commonly experience illusions and hallucinations. Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is associated with depression.
You may also like to solve these questions
A patient has progressive memory deficit associated with dementia. Which nursing intervention would best help the individual function in the environment?
- A. Assist the patient to perform simple tasks by giving step-by-step directions.
- B. Reduce frustration by performing activities of daily living for the patient.
- C. Stimulate intellectual function by discussing new topics with the patient.
- D. Promote the use of the patient's sense of humor by telling jokes.
Correct Answer: A
Rationale: Patients with a cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the patient is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the patient. Patients with cognitive deficits may lose their sense of humor and find jokes meaningless.
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.
Which description of patient behavior best applies to a hallucination?
- A. Looking at shadows on a wall and says, 'I see scary faces'
- B. Stating, 'I feel bugs crawling on my legs and biting me'
- C. Becoming anxious when the nurse leaves his or her bedside
- D. Trying to hit the nurse when vital signs are taken
Correct Answer: B
Rationale: A hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The incorrect options are examples of behaviors that sometimes occur during delirium and are related to fluctuating levels of awareness and misinterpreted stimuli.
What is the priority nursing diagnosis for a patient experiencing fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?
- A. Bathing/hygiene self-care deficit related to altered cerebral function as evidenced by confusion and inability to perform personal hygiene tasks
- B. Risk for injury related to altered cerebral function, misperception of the environment, and unsteady gait
- C. Disturbed thought processes related to medication intoxication as evidenced by confusion, disorientation, and hallucinations
- D. Fear related to sensory perceptual alterations as evidenced by hiding from imagined ferocious dogs
Correct Answer: B
Rationale: The physical safety of the patient is the highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful; when the patient exercises poor judgment; and when the patient's sensorium is clouded. The other diagnoses may be concerns but are lower priorities.
A patient diagnosed with moderate to severe Alzheimer's disease has a dressing and grooming self-care deficit. The nurse notes that the patient is wearing mismatched clothing and has poor personal hygiene. Which interventions should be included in the patient's plan of care?
- A. Provide clothing with elastic and hook-and-loop closures.
- B. Label clothing with the patient's name and name of the item.
- C. Administer antianxiety medication before bathing and dressing.
- D. Provide necessary items and direct the patient to proceed independently.
- E. If the patient resists, use distraction and then try again after a short interval.
Correct Answer: A,B,E
Rationale: Providing clothing with elastic and hook-and-loop closures facilitates patient independence. Labeling clothing with the patient's name and the name of the item maintains patient identity and dignity (and provides information if the patient has agnosia). When a patient resists, using distraction and trying again after a short interval are appropriate because patient moods are often labile; the patient may be willing to cooperate during a later opportunity. Providing the necessary items for grooming and directing the patient to proceed independently are inappropriate. Staff members are prepared to coach by giving step-by-step directions for each task as it occurs. Administering anxiolytic medication before bathing and dressing is inappropriate. This measure would result in unnecessary overmedication.