NUR 471 Exam 3 Practice
Comprehensive Assessment with Exam
Questions and Correct Answers,
Complete A+ Guide.
THIS EXAM FEATURES:ACTUAL EXAM QUESTIONS & CORRECT ANSWERS.
Domains of cognitive functioning
answer✓✓lower level: attention and orientation
Higher level: ability to problem solve, learn and retain info in long-term memory, use language, visually
perceive the environment, read social situations
Epidemiology of delirium
answer✓✓common complication of hospitalization especially in older pts
Up to 80% in ICU
Risk factors of delirium
answer✓✓-cognitive impairment
-older age
-severity of disease-infection
-multiple comorbidities
-polypharm
-ICU
-hearing or vision issues not addressed
-fractures
-surgery
-stroke
-aphasia
-vison impairment
,-restrain use
-changes in hospital rooms
Delerium
answer✓✓acute cog disturbance and often reversible condition that is common in hospitalized pts
Key findings in detecting delirium in older adults
answer✓✓-fluctuating nature of delirium
-lack of delirium education
-communicatio barriers
-insufficient use of assessment tools
-poor understanding of delirium
-perception of delirium as burdensome
Assessment for delirium
answer✓✓-assess when a patient abruptly demonstrates a reduced clarity of awareness of the
environment
-orientation to the person is usually intact
-perceptual disturbances like illusions and hallucinations
-may be difficult to process stimuli in the environment which compromises safety
-hyperactive or hypoactive delirium
Illusions
answer✓✓error in perception of sensory stimuli
Nursing diagnosis for delirium
answer✓✓risk for injury
Acute confusion
Risk for deficient fluid volume
Disturbed sleep pattern/sleep deprivation
, Outcome criteria for delirium
answer✓✓-pt will remain safe and free from injury while in the hospital
-during periods of clarity pt will be orientated
-patient will remain free from falls and injury while confused with the aid of nursing safety measures
Interventions for delirium
answer✓✓-administer prn meds for anxiety
-assist with ADLS and nutrition
-possible restraints
-ack pts fears and feelings
-info about whats happening
-limit need for decision making
-accept pts percetpions of reality
-orient pt
-slowly approach pt
-introduce self, communicate with direct statements
-encourage fam to stay
-well lit hazard free environment
-pt identification
-consistent environment and daily routine
-cues
-low stimuli environment
Dementia
answer✓✓progressive deterioration of cognitive functioning and global impairment of intellect
DSM5 criteria for major neurocognitive disorder
answer✓✓-evidence of significant cog decline from previous level of performance in one or more
cognitive domains (complex attention, executive function, learning and memory, language, perceptual-
motor or social cognition
-declines interfere with independence
Comprehensive Assessment with Exam
Questions and Correct Answers,
Complete A+ Guide.
THIS EXAM FEATURES:ACTUAL EXAM QUESTIONS & CORRECT ANSWERS.
Domains of cognitive functioning
answer✓✓lower level: attention and orientation
Higher level: ability to problem solve, learn and retain info in long-term memory, use language, visually
perceive the environment, read social situations
Epidemiology of delirium
answer✓✓common complication of hospitalization especially in older pts
Up to 80% in ICU
Risk factors of delirium
answer✓✓-cognitive impairment
-older age
-severity of disease-infection
-multiple comorbidities
-polypharm
-ICU
-hearing or vision issues not addressed
-fractures
-surgery
-stroke
-aphasia
-vison impairment
,-restrain use
-changes in hospital rooms
Delerium
answer✓✓acute cog disturbance and often reversible condition that is common in hospitalized pts
Key findings in detecting delirium in older adults
answer✓✓-fluctuating nature of delirium
-lack of delirium education
-communicatio barriers
-insufficient use of assessment tools
-poor understanding of delirium
-perception of delirium as burdensome
Assessment for delirium
answer✓✓-assess when a patient abruptly demonstrates a reduced clarity of awareness of the
environment
-orientation to the person is usually intact
-perceptual disturbances like illusions and hallucinations
-may be difficult to process stimuli in the environment which compromises safety
-hyperactive or hypoactive delirium
Illusions
answer✓✓error in perception of sensory stimuli
Nursing diagnosis for delirium
answer✓✓risk for injury
Acute confusion
Risk for deficient fluid volume
Disturbed sleep pattern/sleep deprivation
, Outcome criteria for delirium
answer✓✓-pt will remain safe and free from injury while in the hospital
-during periods of clarity pt will be orientated
-patient will remain free from falls and injury while confused with the aid of nursing safety measures
Interventions for delirium
answer✓✓-administer prn meds for anxiety
-assist with ADLS and nutrition
-possible restraints
-ack pts fears and feelings
-info about whats happening
-limit need for decision making
-accept pts percetpions of reality
-orient pt
-slowly approach pt
-introduce self, communicate with direct statements
-encourage fam to stay
-well lit hazard free environment
-pt identification
-consistent environment and daily routine
-cues
-low stimuli environment
Dementia
answer✓✓progressive deterioration of cognitive functioning and global impairment of intellect
DSM5 criteria for major neurocognitive disorder
answer✓✓-evidence of significant cog decline from previous level of performance in one or more
cognitive domains (complex attention, executive function, learning and memory, language, perceptual-
motor or social cognition
-declines interfere with independence
