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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.
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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 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.
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.
What is the priority nursing intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations?
- A. Avoidance of physical contact
- B. High level of sensory stimulation
- C. Careful observation and supervision
- D. Application of wrist and ankle restraints
Correct Answer: C
Rationale: Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient remains safe and free from injury. Physical contact during care cannot be avoided. Restraint is a last resort, and sensory stimulation should be reduced.
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.