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Which nursing intervention is appropriate to use for patients diagnosed with either delirium or dementia?
- A. Speak in a loud, firm voice.
- B. Touch the patient before speaking.
- C. Reintroduce the health care worker at each contact.
- D. When the patient becomes aggressive, use physical restraint instead of medication.
Correct Answer: C
Rationale: Short-term memory is often impaired in patients with delirium and dementia. Reorientation to staff is often necessary with each contact to minimize misperceptions, reduce anxiety level, and secure cooperation. Loud voices may be frightening or sound angry. Speaking before touching prevents the patient from feeling threatened. Physical restraint is not appropriate; the least restrictive measure should be used.
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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.
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.
During morning care, an assistive personnel asks a patient diagnosed with dementia, 'How was your night?' The patient replies, 'It was lovely. I went out to dinner and a movie with my friend.' Which term applies to the patient's response?
- A. Sundown syndrome
- B. Confabulation
- C. Perseveration
- D. Delirium
Correct Answer: B
Rationale: Confabulation is the making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The patient's response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario.
A patient diagnosed with stage 1 mild Alzheimer's disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time?
- A. Complicated grieving
- B. Impaired memory
- C. Self-care deficit
- D. Caregiver role strain
Correct Answer: B
Rationale: Memory impairment is present and expected in stage 1 mild Alzheimer's disease. Patients diagnosed with early Alzheimer's disease often have difficulty remembering names, so socialization is minimized. Data are not present to support the other diagnoses.