Question 1

A patient experiencing fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs! Get them off!" Which problem is the patient experiencing?

Accepted Answer

The patient feels bugs crawling on both legs, although no sensory stimulus is actually present. This description coincides with the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium.

Question 2

A patient has progressive memory deficit associated with dementia. Which nursing intervention would best help the individual function in the environment?

Accepted Answer

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.

Question 3

Consider these problems: apolipoprotein E (apoE) malfunction, neuritic plaques, neurofibrillary tangles, granulovascular degeneration, and brain atrophy. Which condition corresponds to this group?

Accepted Answer

The problems are all aspects of the pathophysiologic characteristics of Alzheimer disease.

Question 4

An older adult takes digoxin and hydrochlorothiazide daily, as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, this adult developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of:

Accepted Answer

Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems.

Question 5

A patient diagnosed with Alzheimer disease wanders at night. Which action should the nurse recommend for a family to use in the home to enhance safety?

Accepted Answer

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.

Question 6

A patient experiencing fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response?

Accepted Answer

When hallucinations are present, the nurse should acknowledge the patient's feelings and state the nurse's perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patient's perception without offering help does not emotionally support the patient. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions.

Question 7

Goals and desired outcomes for an older adult patient experiencing delirium caused by fever and dehydration will focus on:

Accepted Answer

The desired overall goal is that the patient with delirium will return to the level of functioning held before the development of delirium. Demonstrating motor responses to noxious stimuli is an appropriate indicator for a patient whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a patient experiencing delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for the patient with sensorium problems related to delirium.

Question 8

What is the priority nursing intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations?

Accepted Answer

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.

Question 9

A patient diagnosed with stage 2 moderate Alzheimer 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 assessed as:

Accepted Answer

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.

Question 10

When used for treatment of patients diagnosed with Alzheimer disease, which medication would be expected to antagonize N-methyl-D-aspartate (NMDA) channels rather than cholinesterase?

Accepted Answer

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 disease.

Question 11

During morning care, a nursing assistant 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?

Accepted Answer

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.

Question 12

Consider these health problems: Lewy body disease, Pick disease, and Korsakoff syndrome. Which term unifies these problems?

Accepted Answer

The listed health problems are all forms of dementia.

Question 13

An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident?

Accepted Answer

Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. No evidence of memory loss is revealed in this scenario.

Question 14

Which description best applies to a hallucination? A patient:

Accepted Answer

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.

Question 15

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?

Accepted Answer

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.

Question 16

An older adult patient in an intensive care unit is experiencing visual and auditory illusions. Which nursing intervention will be most helpful?

Accepted Answer

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.

Question 17

What is the priority nursing diagnosis for a patient experiencing fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?

Accepted Answer

The physical safety of the patient is the highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful; when the patient exercises poor judgment; and when the patient's sensorium is clouded. The other diagnoses may be concerns but are lower priorities.

Question 18

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 disease is evident?

Accepted Answer

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.

Question 19

Which environmental adjustment should the nurse make for a patient experiencing delirium with perceptual alterations?

Accepted Answer

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.

Question 20

A patient diagnosed with stage 1 mild Alzheimer 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?

Accepted Answer

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.

Quiz 18: Neurocognitive Disorders