Dementia and delirium || EXAM QUESTIONS WITH
ACTUAL SOLUTIONS!!!
A 72-year-old patient hospitalized with pneumonia is disoriented and confused 2 days after
admission. Which assessment information obtained by the nurse about the patient indicates
that the patient is experiencing delirium rather than dementia?
a. The patient is disoriented to place and time but oriented to person.
b. The patient has a history of increasing confusion over several years.
c. The patient's speech is fragmented and incoherent.
d. The patient was oriented and alert when admitted. correct answers Correct Answer: D
Rationale: The onset of delirium occurs acutely. The degree of disorientation does not
differentiate between delirium and dementia. Increasing confusion for several years is
consistent with dementia. Fragmented and incoherent speech may occur with either delirium
or dementia.
Cognitive Level: Application Text Reference: p. 1562
Nursing Process: Assessment NCLEX: Physiological Integrity
When developing a plan of care for a hospitalized patient with moderate dementia, which
intervention will the nurse include?
a. Reminding the patient frequently about being in the hospital
b. Placing suction at the bedside to decrease the risk for aspiration
c. Providing complete personal hygiene care for the patient
d. Repositioning the patient frequently to avoid skin breakdown correct answers Correct
Answer: A
Rationale: The patient with moderate dementia will have problems with short- and long-term
memory and will need reminding about the hospitalization.
The other interventions would be used for a patient with severe dementia, who would have
difficulty with swallowing, self-care, and immobility.
3. When administering a mental status examination to a patient with delirium, the nurse
should
a. give the examination when the patient is well-rested.
b. reorient the patient as needed during the examination.
c. choose a place without distracting environmental stimuli.
d. medicate the patient first to reduce anxiety. correct answers Correct Answer: C
Rationale: Because overstimulation by environmental factors can distract the patient from the
task of answering the nurse's questions, these stimuli should be avoided.
The nurse will not wait to give the examination because action to correct the delirium should
occur as soon as possible.
Reorienting the patient is not appropriate during the examination.
Antianxiety medications may increase the patient's delirium.
, To protect a patient from injury during an episode of delirium, the most appropriate action by
the nurse is to
a. have a close family member remain with the patient and provide reassurance.
b. assign a staff member to stay with the patient and offer frequent reorientation.
c. ask the health care provider about ordering an antipsychotic drug.
d. secure the patient in bed with a soft chest restraint. correct answers Correct Answer: B
Rationale: The priority goal is to protect the patient from harm, and a staff member will be
most experienced in providing safe care.
Visits by family members are helpful in reorienting the patient, but families should not be
responsible for protecting patients from injury.
Antipsychotic medications may be ordered, but only if other measures are not effective
because these medications have multiple side effects.
Restraints are sometimes used but tend to increase agitation and disorientation.
A family member of a patient with possible Alzheimer's disease asks the nurse the purpose of
the Mini-Mental State Examination (MMSE). Which response by the nurse is appropriate?
a. The MMSE helps in establishing the diagnosis of Alzheimer's disease (AD).
b. The MMSE is useful in determining the degree of mental impairment.
c. The MMSE determines the choice of the most appropriate treatment.
d. The MMSE aids in differentiating acute delirium from chronic dementia. correct answers
Correct Answer: B
Rationale: The MMSE establishes the degree of mental impairment at the time it is given.
It does not establish a diagnosis of AD but when given repeatedly over time may help to
determine the progression of AD.
The choice of treatment is made on the basis of multiple data, not just the MMSE.
The MMSE may be abnormal with either delirium or dementia and is not useful in
determining which condition the patient has.
When administering a mental status examination to a patient, the nurse suspects depression
when the patient responds with
a. "I don't know."
b. "Is that the right answer?"
c. "Wait, let me think about that."
d. "Who are those people over there?" correct answers Correct Answer: A
Rationale: Answers such as "I don't know" are more typical of depression.
The response "Who are those people over there?" is more typical of the distraction seen in a
patient with delirium.
The remaining two answers are more typical of a patient with dementia.
ACTUAL SOLUTIONS!!!
A 72-year-old patient hospitalized with pneumonia is disoriented and confused 2 days after
admission. Which assessment information obtained by the nurse about the patient indicates
that the patient is experiencing delirium rather than dementia?
a. The patient is disoriented to place and time but oriented to person.
b. The patient has a history of increasing confusion over several years.
c. The patient's speech is fragmented and incoherent.
d. The patient was oriented and alert when admitted. correct answers Correct Answer: D
Rationale: The onset of delirium occurs acutely. The degree of disorientation does not
differentiate between delirium and dementia. Increasing confusion for several years is
consistent with dementia. Fragmented and incoherent speech may occur with either delirium
or dementia.
Cognitive Level: Application Text Reference: p. 1562
Nursing Process: Assessment NCLEX: Physiological Integrity
When developing a plan of care for a hospitalized patient with moderate dementia, which
intervention will the nurse include?
a. Reminding the patient frequently about being in the hospital
b. Placing suction at the bedside to decrease the risk for aspiration
c. Providing complete personal hygiene care for the patient
d. Repositioning the patient frequently to avoid skin breakdown correct answers Correct
Answer: A
Rationale: The patient with moderate dementia will have problems with short- and long-term
memory and will need reminding about the hospitalization.
The other interventions would be used for a patient with severe dementia, who would have
difficulty with swallowing, self-care, and immobility.
3. When administering a mental status examination to a patient with delirium, the nurse
should
a. give the examination when the patient is well-rested.
b. reorient the patient as needed during the examination.
c. choose a place without distracting environmental stimuli.
d. medicate the patient first to reduce anxiety. correct answers Correct Answer: C
Rationale: Because overstimulation by environmental factors can distract the patient from the
task of answering the nurse's questions, these stimuli should be avoided.
The nurse will not wait to give the examination because action to correct the delirium should
occur as soon as possible.
Reorienting the patient is not appropriate during the examination.
Antianxiety medications may increase the patient's delirium.
, To protect a patient from injury during an episode of delirium, the most appropriate action by
the nurse is to
a. have a close family member remain with the patient and provide reassurance.
b. assign a staff member to stay with the patient and offer frequent reorientation.
c. ask the health care provider about ordering an antipsychotic drug.
d. secure the patient in bed with a soft chest restraint. correct answers Correct Answer: B
Rationale: The priority goal is to protect the patient from harm, and a staff member will be
most experienced in providing safe care.
Visits by family members are helpful in reorienting the patient, but families should not be
responsible for protecting patients from injury.
Antipsychotic medications may be ordered, but only if other measures are not effective
because these medications have multiple side effects.
Restraints are sometimes used but tend to increase agitation and disorientation.
A family member of a patient with possible Alzheimer's disease asks the nurse the purpose of
the Mini-Mental State Examination (MMSE). Which response by the nurse is appropriate?
a. The MMSE helps in establishing the diagnosis of Alzheimer's disease (AD).
b. The MMSE is useful in determining the degree of mental impairment.
c. The MMSE determines the choice of the most appropriate treatment.
d. The MMSE aids in differentiating acute delirium from chronic dementia. correct answers
Correct Answer: B
Rationale: The MMSE establishes the degree of mental impairment at the time it is given.
It does not establish a diagnosis of AD but when given repeatedly over time may help to
determine the progression of AD.
The choice of treatment is made on the basis of multiple data, not just the MMSE.
The MMSE may be abnormal with either delirium or dementia and is not useful in
determining which condition the patient has.
When administering a mental status examination to a patient, the nurse suspects depression
when the patient responds with
a. "I don't know."
b. "Is that the right answer?"
c. "Wait, let me think about that."
d. "Who are those people over there?" correct answers Correct Answer: A
Rationale: Answers such as "I don't know" are more typical of depression.
The response "Who are those people over there?" is more typical of the distraction seen in a
patient with delirium.
The remaining two answers are more typical of a patient with dementia.
