Nokea
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.
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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.
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.
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.
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.
A patient diagnosed with Alzheimer's disease wanders at night. Which action should the nurse recommend for a family to use in the home to enhance safety?
- A. Place throw rugs on tile or wooden floors.
- B. Place locks at the tops of doors.
- C. Encourage daytime napping.
- D. Obtain a bed with side rails.
Correct Answer: B
Rationale: Placing door locks at the top of the door makes it more difficult for the patient with dementia to unlock the door because the ability to look up and reach upward is diminished. All throw rugs should be removed to prevent falls. The patient will try to climb over side rails, increasing the risk for injury and falls. Day napping should be discouraged with the hope that the patient will sleep during the night.