Nokea
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.
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During the change of shift report in the intensive care unit, the nurse learns that a client has developed signs of delirium over the past 8 hours. Which behavior documented in the nursing notes would be consistent with delirium?
- A. Unable to identify a water pitcher
- B. Unable to transfer to sitting position
- C. Difficulty with verbal expression
- D. Disoriented to person
Correct Answer: D
Rationale: Delirium is characterized by sudden onset and disorientation, such as to person, unlike dementia, which involves agnosia, apraxia, or aphasia.
The nurse is working with a client who has hallucinations and delusions. The client tells the nurse she cannot take a shower because she is waiting for her husband to take her home. Which response by the nurse is best in this situation?
- A. It would be best if you just took your shower now.
- B. You seem anxious and upset.
- C. You have plenty of time to shower before it's time to go home.
- D. Why are you thinking you're going home?
Correct Answer: C
Rationale: Going along with the delusion without reinforcing it allows the client to proceed with activities calmly.
A nurse working in an assisted living facility is holding an in-service for the nursing assistants. The nurse reviews common behaviors associated with cognitive deterioration associated with dementia. Which would cause the nurse to know that the assistants correctly understood if it were expressed during a postsets?
- A. The clients should be able to ask us for items they need
- B. The clients may not recognize their family when they come to visit
- C. The clients who are ambulatory can still carry out activities of daily living independently
- D. The clients should know when to come to the dining room for meals
Correct Answer: B
Rationale: Dementia involves agnosia, leading to failure to recognize familiar people, unlike intact executive functioning or independent ADLs.
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.
The nurse caring for an elderly woman with dementia has asked the woman's children to bring old photo albums when they visit. Which best describes the usefulness of viewing photos when caring for the dementia client?
- A. Viewing photos is a form of reminiscence therapy for the client.
- B. Sharing photos will encourage interaction with other clients.
- C. This can help the children to correctly identify old photographs.
- D. Talking about the photos will encourage the client to live in the past.
Correct Answer: A
Rationale: Reminiscence therapy using photos stimulates remote memory, which is less impaired in dementia.