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A patient who is hospitalized with pneumonia is disoriented and confused 3 days
after admission. Which information indicates that the patient is experiencing
delirium rather than dementia?
a. The patient was oriented and alert when admitted.
b. The patient's speech is fragmented and incoherent.
c. The patient is oriented to person but disoriented to place and time.
d. The patient has a history of increasing confusion over several years. - ANS -a.
The patient was oriented and alert when admitted.
Which intervention will the nurse include in the plan of care for a patient with
moderate dementia who had a fractured hip repair 2 days ago?
a. Provide complete personal hygiene care for the patient.
b. Remind the patient frequently about being in the hospital.
c. Reposition the patient frequently to avoid skin breakdown.
d. Place suction at the bedside to decrease the risk for aspiration. - ANS -b.
Remind the patient frequently about being in the hospital.
When administering a mental status examination to a patient with delirium, the
nurse should
a. wait until the patient is well-rested.
b. administer an anxiolytic medication.
,c. choose a place without distracting stimuli.
d. reorient the patient during the examination. - ANS -c. choose a place without
distracting stimuli.
The nurse is concerned about a postoperative patient's risk for injury during an
episode of
delirium. The most appropriate action by the nurse is to
a. secure the patient in bed using a soft chest restraint.
b. ask the health care provider to order an antipsychotic drug.
c. instruct family members to remain at the patient's bedside and prevent injury.
d. assign unlicensed assistive personnel (UAP) to stay with and reorient the
patient. - ANS -d. assign unlicensed assistive personnel (UAP) to stay with and
reorient the patient.
A patient seen in the outpatient clinic is diagnosed with mild cognitive
impairment (MCI).
Which action will the nurse include in the plan of care?
a. Suggest a move into an assisted living facility.
b. Schedule the patient for more frequent appointments.
c. Ask family members to supervise the patient's daily activities.
d. Discuss the preventive use of acetylcholinesterase medications. - ANS -b.
Schedule the patient for more frequent appointments.
The nurse is administering a mental status examination to a patient who has
hypertension. The
nurse suspects depression when the patient responds to the nurse's questions
with
,a. "Is that right?" c. "Wait, let me think about that."
b. "I don't know." d. "Who are those people over there?" - ANS -b. "I don't know."
A patient is diagnosed with moderate dementia after multiple strokes. During
assessment of
the patient, the nurse would expect to find
a. excessive nighttime sleepiness.
b. difficulty eating and swallowing.
c. loss of recent and long-term memory.
d. fluctuating ability to perform simple tasks. - ANS -c. loss of recent and long-
term memory.
Which action will help the nurse determine whether a new patient's confusion is
caused by
dementia or delirium?
a. Ask about a family history of dementia.
b. Administer the Mini-Mental Status Exam.
c. Use the Confusion Assessment Method tool.
d. Obtain a list of the patient's usual medications. - ANS -c. Use the Confusion
Assessment Method tool.
A 72-yr-old patient is brought to the clinic by the patient's spouse, who reports
that the patient
is unable to solve common problems around the house. To obtain information
about the
patient's current mental status, which question should the nurse ask the patient?
, a. "Are you sad right now?"
b. "How is your self-image?"
c. "What did you eat for lunch?"
d. "Where were you were born?" - ANS -c. "What did you eat for lunch?"
Which nursing action will be most effective in ensuring daily medication
compliance for a
patient with mild dementia?
a. Setting the medications up monthly in a medication box
b. Having the patient's family member administer the medication
c. Posting reminders to take the medications in the patient's house
d. Calling the patient weekly with a reminder to take the medication - ANS -b.
Having the patient's family member administer the medication
A patient with severe Alzheimer's disease is being admitted to the hospital for
surgery. Which intervention should the nurse include in the plan of care?
a. Encourage the patient to discuss events from the past
b. Maintain a consistent daily routine for the patient's care.
c. Reorient the patient to the date and time every 2-3 hours.
d. Provide the patient with current newspapers and magazines. - ANS -b. Maintain
a consistent daily routine for the patient's care.
The day shift nurse at a long-term care facility learns a patient with dementia
experienced sundowning the last two days. What action should the nurse take?
a. Have the patient take a mid-morning nap.
b. Keep the window blinds open during the day.