C HAPTER 23: N EUROCOGNITIVE D ISORDERS
Varcarolis’ Foundations of Psychiatric-Mental Health Nursing: 8th Edition
MULTIPLE CHOICE
1. An older adult patient in the intensive care unit has visual and auditory
illusions. Which intervention will be most helpful?
a. Using the patients glasses and hearing aids
b. Placing personall y meaningful objects in view
c. Placing large clocks and calendars on the wall
d. Assuring that the room is brightl y lit but very quiet at all times
ANS: A
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 a lterations.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
REF: 433 TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
2. A patient diagnosed with Alzheimers disease calls the fire department
saying, My smoke detectors are going off. Firefighters investigate and
discover that the patient misinterpreted the telephone ringing. Which
problem is this patient experiencing?
a. Hyperoralit y
, b. Aphasia
c. Apraxia
d. Agnosia
ANS: D
Agnosia is the inabilit y to recognize familiar objects, part s of ones
body, or ones own reflection in a mirror. Hyperoralit y refers to placing
objects in the mouth. Aphasia refers to the loss of language abilit y.
Apraxia refers to the loss of purposeful movements, such as being
unable to dress.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: 437 TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrit y
3. During morning care, a nurse asks a patient diagnosed with dementia, How
was your night? The patient replies, It was lovel y. I wen t out to dinner
and a movie with m y friend. Which term applies to the patients response?
a. Sundown syndrome
b. Confabulation
c. Perseveration
d. Delirium
ANS: B
Confabulation refers to making up of stories or answers to questions by
a person who does not rememb er. It is a defensive tactic to protect
self-esteem and prevent others from noticing memory loss. The patients
response was not sundown syndrome. Perseveration refers to repeating
, a word or phrase over and over. Delirium is not present in this
scenario.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: 437 TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrit y
4. A nurse counsels the famil y of a patient diagnosed with Alzheimers
disease who lives at home and wanders at nigh t. Which action is most
important for the nurse to recommend to enhance safet y?
a. Appl y a medical alert bracelet to the patient.
b. Place locks at the tops of doors.
c. Discourage daytime napping.
d. Obtain a bed with side rails.
ANS: B
Placing door locks at the to p of the door makes it more difficult for the
patient with dementia to unlock the door because the abilit y to look up
and reach upward is diminished. The patient will try to climb over side
rails increasing the risk for injury and falls. Avoiding daytime n aps
may improve the patients sleep pattern but does not assure safet y. A
medical alert bracelet will be helpful if the patient leaves the home,
but it does not prevent wandering or assure the patients safet y.
PTS: 1 DIF: Cognitive Level: Anal yze (Anal ysi s) REF: 448
TOP: Nursing Process: Planning MSC: Client Needs:
Safe, Effective Care Environment
Varcarolis’ Foundations of Psychiatric-Mental Health Nursing: 8th Edition
MULTIPLE CHOICE
1. An older adult patient in the intensive care unit has visual and auditory
illusions. Which intervention will be most helpful?
a. Using the patients glasses and hearing aids
b. Placing personall y meaningful objects in view
c. Placing large clocks and calendars on the wall
d. Assuring that the room is brightl y lit but very quiet at all times
ANS: A
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 a lterations.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
REF: 433 TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
2. A patient diagnosed with Alzheimers disease calls the fire department
saying, My smoke detectors are going off. Firefighters investigate and
discover that the patient misinterpreted the telephone ringing. Which
problem is this patient experiencing?
a. Hyperoralit y
, b. Aphasia
c. Apraxia
d. Agnosia
ANS: D
Agnosia is the inabilit y to recognize familiar objects, part s of ones
body, or ones own reflection in a mirror. Hyperoralit y refers to placing
objects in the mouth. Aphasia refers to the loss of language abilit y.
Apraxia refers to the loss of purposeful movements, such as being
unable to dress.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: 437 TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrit y
3. During morning care, a nurse asks a patient diagnosed with dementia, How
was your night? The patient replies, It was lovel y. I wen t out to dinner
and a movie with m y friend. Which term applies to the patients response?
a. Sundown syndrome
b. Confabulation
c. Perseveration
d. Delirium
ANS: B
Confabulation refers to making up of stories or answers to questions by
a person who does not rememb er. It is a defensive tactic to protect
self-esteem and prevent others from noticing memory loss. The patients
response was not sundown syndrome. Perseveration refers to repeating
, a word or phrase over and over. Delirium is not present in this
scenario.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: 437 TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrit y
4. A nurse counsels the famil y of a patient diagnosed with Alzheimers
disease who lives at home and wanders at nigh t. Which action is most
important for the nurse to recommend to enhance safet y?
a. Appl y a medical alert bracelet to the patient.
b. Place locks at the tops of doors.
c. Discourage daytime napping.
d. Obtain a bed with side rails.
ANS: B
Placing door locks at the to p of the door makes it more difficult for the
patient with dementia to unlock the door because the abilit y to look up
and reach upward is diminished. The patient will try to climb over side
rails increasing the risk for injury and falls. Avoiding daytime n aps
may improve the patients sleep pattern but does not assure safet y. A
medical alert bracelet will be helpful if the patient leaves the home,
but it does not prevent wandering or assure the patients safet y.
PTS: 1 DIF: Cognitive Level: Anal yze (Anal ysi s) REF: 448
TOP: Nursing Process: Planning MSC: Client Needs:
Safe, Effective Care Environment
