Question 1

A client diagnosed with dementia is disoriented, ataxic, and wanders. Which is the priority nursing diagnosis?

Accepted Answer

The priority nursing diagnosis in this case is Risk for injury because the client's wandering behavior puts them at risk for falls, getting lost, or other accidents. Ataxia further increases the risk for falls and other injuries. While disturbed thought processes, self-care deficit, and altered health-care maintenance are all important considerations in caring for a client with dementia, addressing the immediate risk for injury should be the priority.

Question 2

Which symptom should a nurse identify that would differentiate clients diagnosed with dementia disorders from clients diagnosed with amnesic disorders?

Accepted Answer

Impairment of abstract thinking and judgment is a symptom of dementia disorders that distinguishes them from amnesic disorders. While amnesic disorders primarily involve memory impairment, dementia disorders affect multiple cognitive functions, including language, spatial orientation, and executive function. Confabulation can occur in both dementia and amnesic disorders, and disorientation is a common symptom in both as well. However, the rapid onset of disorientation is more indicative of delirium than dementia.

Question 3

An older client has recently moved to a nursing home. The client has trouble concentrating and socially isolates. A physician believes the client would benefit from medication therapy. Which medication should the nurse expect the physician to prescribe?

Accepted Answer

The nurse should expect the physician to prescribe sertraline (Zoloft)to improve the client's social functioning and concentration levels.Sertraline (Zoloft)is an SSRI (selective serotonin reuptake inhibitor)antidepressant.Depression is the most common mental illness in older adults and is often misdiagnosed as neurocognitive disorder.

Question 4

After 1 week of continuous mental confusion, an elderly African American client is admitted with a preliminary diagnosis of Alzheimer's dementia. What should cause the nurse to question this diagnosis?

Accepted Answer

Alzheimer's dementia typically develops gradually over time, and sudden onset of confusion and cognitive impairment may indicate another underlying condition. The other options presented are not valid reasons to question the diagnosis.

Question 5

A client is experiencing progressive changes in memory that have interfered with personal, social, and occupational functioning. The client exhibits poor judgment and has a short attention span. A nurse should recognize these as classic signs of which condition?

Accepted Answer

The classic signs of dementia include progressive changes in memory, poor judgment, and a short attention span. These changes interfere with personal, social, and occupational functioning over time. Mania is a mood disorder characterized by an elevated or irritable mood, increased energy, and reduced need for sleep. Delirium is a sudden onset of confusion, often caused by an underlying medical condition or medication. Parkinsonism is a group of motor symptoms, including tremor, rigidity, and bradykinesia, that are characteristic of Parkinson's disease.

Question 6

A client is diagnosed with late-stage Alzheimer's dementia. To address the client's symptoms, which nursing intervention should take priority?

Accepted Answer

Promoting the client's dignity by providing comfort, safety, and self-care measures is a priority. At the late stages of Alzheimer's dementia, the focus of care should be on maintaining the client's quality of life by meeting their basic needs such as food, shelter, and safety. The client may not be able to participate in social activities or benefit from group therapies due to the cognitive decline. Providing assistive devices may also be challenging due to decreased ability to communicate and comprehend their use.

Question 7

A client diagnosed with Alzheimer's dementia has impairments of memory and judgment and is incapable of performing activities of daily living. Which nursing intervention should take priority?

Accepted Answer

The priority nursing intervention for a client with Alzheimer's dementia who is incapable of performing activities of daily living is to assist with bathing and toileting. This ensures the client's hygiene and comfort, and helps prevent complications such as infections or falls. Presenting evidence of objective reality may not improve cognition, as the client's impairment may be irreversible. Designing a bulletin board and labeling the room can be helpful, but are not as important as assisting with basic needs.

Question 8

A client diagnosed with Alzheimer's dementia can no longer ambulate, does not recognize family members, and communicates with agitated behaviors and incoherent verbalizations. The nurse recognizes these symptoms as indicative of which stage of the illness?

Accepted Answer

The client's inability to ambulate, lack of recognition of family members, and agitated behaviors with incoherent verbalizations are all characteristic of late-stage Alzheimer's dementia. In this stage, the individual is highly dependent on others for basic activities of daily living, exhibits significant cognitive decline, and may experience significant changes in mood, behavior, and communication.

Question 9

A client diagnosed with vascular dementia is discharged to home under the care of his wife. Which information should cause the nurse to question the client's safety?

Accepted Answer

Forgetfulness is an early symptom of dementia that would alert the nurse to question the client's safety at home if the client smokes cigarettes.Vascular dementia is a clinical syndrome of dementia due to significant cerebrovascular disease.The cause of vascular dementia is related to an interruption of blood flow to the brain.High blood pressure and hypertension are significant factors in the etiology.

Question 10

A geriatric nurse is teaching student nurses about the risk factors for the development of delirium in older adults. Which student statement indicates that learning has occurred?

Accepted Answer

Taking multiple medications is a common risk factor for the development of delirium in older adults. Adverse drug interactions and toxicity can occur in this population due to age-related changes in the way the body processes drugs.

Answer: B
 Age-related cognitive changes, such as a decline in attention, memory, and processing speed, can also increase the risk of delirium in older adults.

Answer: C
 A lack of exercise or decreased cerebral blood flow can contribute to changes in mental status, but this is not directly related to the development of delirium.

Answer: D
 Although social isolation can contribute to mental and emotional health problems, it is not typically considered a risk factor for delirium in older adults.

Question 11

A nursing instructor is teaching about donepezil (Aricept). A student asks, "How does this work? Will this cure Alzheimer's dementia?" Which is the appropriate instructor reply?

Accepted Answer

Donepezil works by inhibiting the breakdown of acetylcholine, a neurotransmitter necessary for memory processes. By delaying the destruction of acetylcholine, donepezil can improve cognitive function in individuals with Alzheimer's dementia. However, it does not cure the disease and only serves to delay its progression. Option B, C, and D are incorrect because they refer to dopamine, which is not the neurotransmitter targeted by donepezil.

Question 12

A client diagnosed with Alzheimer's dementia exhibits progressive memory loss, diminished cognitive functioning, and verbal aggression upon experiencing frustration. Which nursing intervention is most appropriate?

Accepted Answer

Scheduling structured daily routines can help to provide a familiar and predictable environment, which can reduce confusion and frustration in clients with Alzheimer's dementia. This, in turn, can decrease verbal aggression and other challenging behaviors. Additionally, structured routines can help to maintain remaining cognitive abilities and promote feelings of security and comfort.

Question 13

A client diagnosed with dementia is exhibiting behavioral problems on a daily basis. At change of shift, the client's behavior escalates from pacing to screaming and flailing. Initially, which action should a nurse implement in this situation?

Accepted Answer

Before jumping to medication or physical restraint, it is important to assess potential triggers and unmet needs that may be causing the behavior. Dementia patients often exhibit behavioral problems as a result of frustration or confusion, and addressing these underlying causes can be more effective in managing the behavior in the long term. Consulting with a psychologist and using behavior modification techniques may also be helpful, but should be a secondary intervention after a thorough assessment of the situation. Physical restraint should only be used as a last resort and in accordance with facility policies and procedures.

Question 14

At what time during a 24-hour period should a nurse expect clients diagnosed with Alzheimer's dementia to exhibit more pronounced symptoms?

Accepted Answer

Clients diagnosed with Alzheimer's dementia often experience more pronounced symptoms during a phenomenon known as "sundowning," which typically occurs in the late afternoon or early evening. This may coincide with a decrease in natural light or increased fatigue, leading to increased confusion, agitation, and even wandering or aggression. It is important for nurses to be aware of this pattern of behavior and to develop interventions to promote a calming, reassuring environment during this time. While symptoms may also occur at other times during the day or night, sundowning is a common occurrence in this population.

Question 15

A client with a history of cerebrovascular accident (CVA) is brought to an emergency department experiencing memory problems, confusion, and disorientation. Based on this client's assessment data, which diagnosis would the nurse expect the physician to assign?

Accepted Answer

The client's history of CVA and presenting symptoms of memory problems, confusion, and disorientation suggest that the physician may diagnose vascular dementia, which is caused by impaired blood flow to the brain. Delirium due to adverse effects of medications typically presents with acute onset and is reversible once the medication is discontinued. Altered thought processes is a broad diagnosis that does not provide a specific etiology. Alzheimer's dementia typically presents with a gradual onset of memory loss and other cognitive deficits, rather than the sudden onset seen in this case.

Question 16

Which symptom should a nurse identify that would differentiate clients diagnosed with dementia from clients diagnosed with mood disorders?

Accepted Answer

Impaired memory is a key feature of dementia that differentiates it from mood disorders. Clients with mood disorders may experience changes in their affect, altered sleep, and concentration, but their memory remains intact.

Quiz 24: Delirium, Dementia, and Amnestic Disorders