Varcarolis Ch. 23 Neurocognitive
Disorders
1. An older adult patient takes multiple medications daily. Over 2 days, the patient developed
confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings
are most characteristic of:
a. delirium.
c. amnestic syndrome.
b. dementia.
d. Alzheimers disease. - ANS a. delirium.
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 Alzheimers disease, a type of dementia, is more insidious. Amnestic syndrome
involves memory impairment without other cognitive problems.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: Page 432 TOP: Nursing Process: Assessment
MSC: Client Needs: Physiological Integrity
2. A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts,
Bugs are crawling on my legs. Get them off! Which problem is the patient experiencing?
a. Aphasia
c. Tactile hallucinations
b. Dystonia
d. Mnemonic disturbance - ANS c. Tactile hallucinations
,The patient feels bugs crawling on both legs, even though no sensory stimulus is actually
present. This description meets 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.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: Page 432-434 TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
3. A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual
alteration begs, Someone get these bugs off me. What is the nurses best response?
a. No bugs are on your legs. You are having hallucinations.
b. I will have someone stay here and brush off the bugs for you.
c. Try to relax. The crawling sensation will go away sooner if you can relax.
d. I dont see any bugs, but I can tell you are frightened. I will stay with you. - ANS d. I dont see
any bugs, but I can tell you are frightened. I will stay with you.
When hallucinations are present, the nurse should acknowledge the patients feelings and state
the nurses 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 patients perception without offering help does not support the
patient emotionally. 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.
PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Page 436 (Box 23-1) TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
4. What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness,
disturbed orientation, and visual and tactile hallucinations?
a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness,
disturbed orientation, and misperception of the environment
, b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion
and inability to perform personal hygiene tasks
c. Disturbed thought processes related to medication intoxication, as evidenced by confusion,
disorientation, and hallucinations
d. Fear related to sensory perceptual alterations as evidenced by visual and tactile
hallucinations - ANS a. Risk for injury related to altered cerebral function, fluctuating levels of
consciousness, disturbed orientation, and misperception of the environment
The physical safety of the patient is of highest priority among the diagnoses given. Many
opportunities for injury exist when a patient misperceives the environment as distorted,
threatening, or harmful or when the patient exercises poor judgment or when the patients
sensorium is clouded. The other diagnoses may be concerns, but are lower priorities.
PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Page 435 | Page 442-443 | Page 452 (Nursing Care Plan 23-1)
TOP: Nursing Process: Diagnosis/Analysis
MSC: Client Needs: Safe, Effective Care Environment
5. What is the priority intervention for a patient diagnosed with delirium who has fluctuating
levels of consciousness, disturbed orientation, and perceptual alterations?
a. Distraction using sensory stimulation
c. Avoidance of physical contact
b. Careful observation and supervision
d. Activation of the bed alarm - ANS b. Careful observation and supervision
Careful observation and supervision are of ultimate importance because an appropriate
outcome would be that the patient will remain safe and free from injury. Physical contact during
care cannot be avoided. Activating a bed alarm is only one aspect of providing for the patients
safety.
PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Page 436 (Box 23-1) | Page 452 (Nursing Care Plan 23-1)
TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment
Disorders
1. An older adult patient takes multiple medications daily. Over 2 days, the patient developed
confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings
are most characteristic of:
a. delirium.
c. amnestic syndrome.
b. dementia.
d. Alzheimers disease. - ANS a. delirium.
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 Alzheimers disease, a type of dementia, is more insidious. Amnestic syndrome
involves memory impairment without other cognitive problems.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: Page 432 TOP: Nursing Process: Assessment
MSC: Client Needs: Physiological Integrity
2. A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts,
Bugs are crawling on my legs. Get them off! Which problem is the patient experiencing?
a. Aphasia
c. Tactile hallucinations
b. Dystonia
d. Mnemonic disturbance - ANS c. Tactile hallucinations
,The patient feels bugs crawling on both legs, even though no sensory stimulus is actually
present. This description meets 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.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: Page 432-434 TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
3. A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual
alteration begs, Someone get these bugs off me. What is the nurses best response?
a. No bugs are on your legs. You are having hallucinations.
b. I will have someone stay here and brush off the bugs for you.
c. Try to relax. The crawling sensation will go away sooner if you can relax.
d. I dont see any bugs, but I can tell you are frightened. I will stay with you. - ANS d. I dont see
any bugs, but I can tell you are frightened. I will stay with you.
When hallucinations are present, the nurse should acknowledge the patients feelings and state
the nurses 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 patients perception without offering help does not support the
patient emotionally. 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.
PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Page 436 (Box 23-1) TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
4. What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness,
disturbed orientation, and visual and tactile hallucinations?
a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness,
disturbed orientation, and misperception of the environment
, b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion
and inability to perform personal hygiene tasks
c. Disturbed thought processes related to medication intoxication, as evidenced by confusion,
disorientation, and hallucinations
d. Fear related to sensory perceptual alterations as evidenced by visual and tactile
hallucinations - ANS a. Risk for injury related to altered cerebral function, fluctuating levels of
consciousness, disturbed orientation, and misperception of the environment
The physical safety of the patient is of highest priority among the diagnoses given. Many
opportunities for injury exist when a patient misperceives the environment as distorted,
threatening, or harmful or when the patient exercises poor judgment or when the patients
sensorium is clouded. The other diagnoses may be concerns, but are lower priorities.
PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Page 435 | Page 442-443 | Page 452 (Nursing Care Plan 23-1)
TOP: Nursing Process: Diagnosis/Analysis
MSC: Client Needs: Safe, Effective Care Environment
5. What is the priority intervention for a patient diagnosed with delirium who has fluctuating
levels of consciousness, disturbed orientation, and perceptual alterations?
a. Distraction using sensory stimulation
c. Avoidance of physical contact
b. Careful observation and supervision
d. Activation of the bed alarm - ANS b. Careful observation and supervision
Careful observation and supervision are of ultimate importance because an appropriate
outcome would be that the patient will remain safe and free from injury. Physical contact during
care cannot be avoided. Activating a bed alarm is only one aspect of providing for the patients
safety.
PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Page 436 (Box 23-1) | Page 452 (Nursing Care Plan 23-1)
TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment
