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Which is believed to be a risk factor specific to the development of delirium?
- A. Increased severity of physical illness
- B. Older age
- C. Baseline cognitive impairment
- D. Gradual decline in functioning
Correct Answer: A
Rationale: Increased severity of physical illness is a primary trigger for delirium, unlike gradual decline, which is characteristic of dementia.
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Which is the most effective intervention for clients with delirium?
- A. Giving detailed explanations
- B. Managing environmental stimuli
- C. Promoting rest with PRN medications
- D. Providing activities for distraction
Correct Answer: B
Rationale: Managing environmental stimuli reduces overstimulation, which is critical for clients with delirium.
A client with dementia gets angry and begins to yell at the nurse during mealtime. The nurse leaves the client's side for 5 to 10 minutes and then returns. Which of the following best explains the nurse's behavior?
- A. The nurse was unsure of how to calm the client.
- B. The nurse was frustrated and needed to take a time-out.
- C. The nurse gave the client a chance to calm down before resuming the meal.
- D. The nurse stepped away to verify the safety of other clients.
Correct Answer: C
Rationale: Leaving briefly allows the client to calm down, leveraging their short memory to resume interaction calmly.
The nurse is performing a health history with a client exhibiting signs of delirium. The nurse asks the client and family members about possible causes of the delirious state. Which would the nurse likely attribute as underlying causes for the client's delirium? Select all that apply.
- A. Recent alcohol use
- B. Dehydration
- C. Use of antihistamines
- D. Sleep disturbances
- E. Use of megadoses of vitamins
- F. Exposure to paint or gasoline
Correct Answer: A,B,C,D,F
Rationale: Delirium can be triggered by alcohol, dehydration, antihistamines, sleep disturbances, and exposure to toxins like paint or gasoline, but not typically by megadoses of vitamins.
Which patient is most likely suffering from dementia?
- A. A 90-year-old male who has experienced progressive mental decline that started with forgetfulness
- B. An 80-year-old female who has been in excellent health until she was admitted through the emergency department with a severe urinary tract infection and is now very anxious and is threatening staff
- C. A 6-year-old child who has just been administered conscious sedation for a closed reduction of a fractured wrist and says that her parents have three sets of eyes
- D. A 22-year-old male who was involved in a motorcycle crash without wearing a helmet now unable to remember where he is
Correct Answer: A
Rationale: Dementia involves progressive memory impairment starting with forgetfulness, unlike delirium or amnestic disorders seen in the other cases.
Which are possible sources of frustrations for nurses caring for persons with dementia? Select all that apply.
- A. The clients do not retain explanations or instructions, so the nurse must repeat the same things continually.
- B. The nurse may get little or no positive response or feedback from clients with dementia.
- C. It can be difficult to remain positive and supportive to clients and family because the outcome is so bleak.
- D. It can be helpful for the nurse to talk to colleagues or even a counselor about personal feelings of depression and grief as the dementia progresses.
- E. The clients may seem not to hear or respond to anything the nurse does.
Correct Answer: A,B,C,E
Rationale: Repetition, lack of response, bleak outcomes, and non-responsiveness contribute to nurse frustration, while discussing feelings is a coping strategy, not a source of frustration.