1. A patient who is hospitalized with pneumonia is disoriented and confused 2 days after admission. Which information
obtained by the nurse about the patient 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 disoriented to place and time but oriented to person.
d. The patient has a history of increasing confusion over several years.
a. The patient was oriented and alert when admitted.
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.
2. When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse
include?
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.
b. Remind the patient frequently about being in the hospital.
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. medicate the patient first to reduce any anxiety.
b. give the examination when the patient is well-rested.
c. reorient the patient as needed during the examination.
d. choose a place without distracting environmental stimuli.
d. choose a place without distracting environmental stimuli.
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.
4. To protect a patient from 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 about ordering an antipsychotic drug.
c. instruct family members to remain with the patient and prevent injury.
d. assign a nursing assistant to stay with the patient and offer frequent reorientation.
d. assign a nursing assistant to stay with the patient and offer frequent reorientation.
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.
,5. Which action will the nurse in the outpatient clinic include in the plan of care for a patient with mild cognitive impairment
(MCI)?
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.
b. Schedule the patient for more frequent appointments.
Ongoing monitoring is recommended for patients with MCI. MCI does not interfere with activities of daily living,
acetylcholinesterase drugs are not used for MCI, and an assisted living facility is not indicated for MCI.
6. 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?
a. "I don't know."
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.
, 7. A 72-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During assessment of the
patient, the nurse would expect to find
a. excessive nighttime sleepiness.
b. difficulty eating and swallowing.
c. variable ability to perform simple tasks.
d. loss of both recent and long-term memory.
d. loss of both recent and long-term memory.
Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent
nighttime awakening. Dementia is progressive, and the patient's ability to perform tasks would not have periods of
improvement. Difficulty eating and swallowing is characteristic of severe dementia.
8. To determine whether a new patient's confusion is caused by dementia or delirium, which action should the nurse take?
a. Assess the patient using the Mini-Mental Status Exam.
b. Obtain a list of the medications that the patient usually takes.
c. Determine whether there is positive family history of dementia.
d. Use the Confusion Assessment Method tool to assess the patient.
d. Use the Confusion Assessment Method tool to assess the patient.
The Confusion Assessment Method tool has been extensively tested in assessing delirium. The other actions will be helpful
in determining cognitive function or risk factors for dementia or delirium, but they will not be useful in differentiating
between dementia and delirium.
obtained by the nurse about the patient 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 disoriented to place and time but oriented to person.
d. The patient has a history of increasing confusion over several years.
a. The patient was oriented and alert when admitted.
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.
2. When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse
include?
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.
b. Remind the patient frequently about being in the hospital.
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. medicate the patient first to reduce any anxiety.
b. give the examination when the patient is well-rested.
c. reorient the patient as needed during the examination.
d. choose a place without distracting environmental stimuli.
d. choose a place without distracting environmental stimuli.
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.
4. To protect a patient from 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 about ordering an antipsychotic drug.
c. instruct family members to remain with the patient and prevent injury.
d. assign a nursing assistant to stay with the patient and offer frequent reorientation.
d. assign a nursing assistant to stay with the patient and offer frequent reorientation.
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.
,5. Which action will the nurse in the outpatient clinic include in the plan of care for a patient with mild cognitive impairment
(MCI)?
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.
b. Schedule the patient for more frequent appointments.
Ongoing monitoring is recommended for patients with MCI. MCI does not interfere with activities of daily living,
acetylcholinesterase drugs are not used for MCI, and an assisted living facility is not indicated for MCI.
6. 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?
a. "I don't know."
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.
, 7. A 72-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During assessment of the
patient, the nurse would expect to find
a. excessive nighttime sleepiness.
b. difficulty eating and swallowing.
c. variable ability to perform simple tasks.
d. loss of both recent and long-term memory.
d. loss of both recent and long-term memory.
Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent
nighttime awakening. Dementia is progressive, and the patient's ability to perform tasks would not have periods of
improvement. Difficulty eating and swallowing is characteristic of severe dementia.
8. To determine whether a new patient's confusion is caused by dementia or delirium, which action should the nurse take?
a. Assess the patient using the Mini-Mental Status Exam.
b. Obtain a list of the medications that the patient usually takes.
c. Determine whether there is positive family history of dementia.
d. Use the Confusion Assessment Method tool to assess the patient.
d. Use the Confusion Assessment Method tool to assess the patient.
The Confusion Assessment Method tool has been extensively tested in assessing delirium. The other actions will be helpful
in determining cognitive function or risk factors for dementia or delirium, but they will not be useful in differentiating
between dementia and delirium.
