Chapter 22: Delirium and Dementia Nursing School Test Banks

Chapter 22: Delirium and Dementia
Linton: Introduction to Medical-Surgical Nursing, 6th Edition

MULTIPLE CHOICE

1. The family of a patient with Alzheimer disease asks the nurse, When will my mother quit being so confused? On what information regarding dementia should the nurse base a response?
a. It is a short-term confusional state that is typically reversible.
b. It is a state of confusion caused primarily by medications.
c. It is a state of confusion that usually begins abruptly and lasts a short period.
d. It is a syndrome that is chronic and irreversible.
ANS: D
Alzheimer disease is a type of dementia that is chronic and irreversible. Delirium is a short-term confusional state that has a sudden onset and is typically reversible.

DIF: Cognitive Level: Knowledge REF: p. 336 OBJ: 1
TOP: Dementia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Basic Care and Comfort

2. A nurse is admitting a patient who has been diagnosed as having confusion. What is the most important observation that the nurse should make regarding this patient?
a. Eating, drinking, and sleeping patterns
b. Behavior, orientation, memory, and sleeping habits
c. Urinary and bowel elimination habits
d. Talking, walking, and sleeping patterns
ANS: B
The first step in assessing a confusional state is to observe the patients behavior, orientation, memory, and sleeping habits.

DIF: Cognitive Level: Comprehension REF: p. 339 OBJ: 6
TOP: Confusion Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

3. While a nurse is dressing a patient who has dementia as a result of Huntington disease, the patient states, I dont want to wear clothes today and begins to resist help putting on her clothes. What is the nurses most appropriate action?
a. Tell the patient that she must wear clothes or she cannot see her family later.
b. Get another nurse to help her force the patient to get dressed.
c. Talk to the patient about her family coming this afternoon and continue to assist the patient gently with dressing.
d. Let the patient go without clothes but make her stay in her room.
ANS: C
When patients with dementia resist activities such as bathing or dressing, avoiding confrontations and diverting their attention elsewhere are best.

DIF: Cognitive Level: Application REF: p. 344-345 OBJ: 6
TOP: Resisting Care KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

4. What are the adaptations to interventions that the Cognitive Developmental Approach (CDA) to caring for patients with dementia designed to achieve?
a. Increase cognitive abilities.
b. Adapt environment to patient.
c. Offer a wide variety of choices.
d. Abolish irrational fears.
ANS: B
The CDA adapts implementations based on the patients cognitive abilities as they are, modifies the environment, and offers limited choices.

DIF: Cognitive Level: Knowledge REF: p. 345 OBJ: 6
TOP: Cognitive Developmental Approach
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

5. A nurse is gathering information from the family of a patient who is experiencing confusion. What important question should the nurse ask the family?
a. Are you sure she is confused? Maybe she just didnt hear what you were saying.
b. When did you first think she might be confused? Tell me exactly what happened.
c. Did something bad happen to her during her childhood?
d. How can you say she is confused? She knows who she is.
ANS: B
Family members may be able to provide helpful information when the patient cannot. The nurse should ask when the symptoms of confusion started and whether the confusion is constant or intermittent.

DIF: Cognitive Level: Application REF: p. 339 OBJ: 6
TOP: Assessing Confusion KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity

6. The family of a patient with dementia expresses concern to the nurse about the patient wandering at night. They are afraid that the patient might get up while they are sleeping and go outside. What is the best advice for the nurse to provide?
a. Apply a vest restraint at night.
b. Perform constant reality orientation.
c. Learn some behavior modification techniques.
d. Put new locks on the outside doors in new places.
ANS: D
Take advantage of the fact that patients with dementia are usually unable to learn new things. They will probably not be able to figure out how to work a new lock.

DIF: Cognitive Level: Application REF: p. 344-345 OBJ: 6
TOP: Dementia Safety KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

7. A nurse is planning for the nutritional needs of a patient with Alzheimer disease. What is the best plan to have the dietary department provide?
a. Pureed diet to be fed with a syringe
b. Foods that the patient can cut up to keep busy and not lose interest in eating
c. Finger foods several times a day
d. High-protein liquid diet
ANS: C
Small, frequent meals are less confusing to patients. Finger foods high in protein and carbohydrates allow patients to feed themselves more easily.

DIF: Cognitive Level: Comprehension REF: p. 344-345 OBJ: 6
TOP: Nutritional Needs KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

8. What initial nursing action should be implemented when assisting a patient with dementia to dress?
a. Hand the patient her clothes and ask her to put them on.
b. Hand the patient each article of clothing separately and ask her to put it on.
c. Assist her with each article, giving specific instructions such as, Put your arm in this hole.
d. Put the patients clothes on without assistance from the patient.
ANS: C
The goal should be to maintain the highest level of functioning possible, but tasks must be broken down into individual steps to be performed one at a time.

DIF: Cognitive Level: Application REF: p. 343 OBJ: 6
TOP: Self-Care Needs KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

9. Reality orientation is helpful for some patients with confusion. What patient diagnosis is most appropriate for the nurse to implement this technique?
a. Organic brain syndrome
b. Senile dementia
c. Senility
d. Acute confusional state
ANS: D
Acute confusional state is another name for delirium. The other choices are other names for dementia. Reality orientation may be helpful for patients with delirium but tends to agitate patients with dementia.

DIF: Cognitive Level: Comprehension REF: p. 340 | p. 344
OBJ: 2 TOP: Reality Orientation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

10. A nurse is assessing a patient for the possibility of confusion. What two major types of confusion should the nurse be aware of to appropriately assess this patient?
a. Acute and chronic senility
b. Temporary and permanent confusion
c. Delirium and dementia
d. Senility and senile dementia
ANS: C
The two major types of confusion are acute confusional states, or delirium, and chronic confusion dementia.

DIF: Cognitive Level: Knowledge REF: p. 336 OBJ: 1
TOP: Types of Confusion KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

11. A patient with delirium repeatedly cries out for her husband. What is the most appropriate initial nursing intervention?
a. Administer Haldol as ordered.
b. Apply restraints so that the patient will not harm herself.
c. Calmly tell the patient that she is in the hospital and that her husband is not there.
d. Call the husband and tell him that he needs to come and stay with his wife.
ANS: C
Anyone dealing with a delirious patient should be calm, warm, and reassuring. Frequent orientation to the surroundings and situation is important as well.

DIF: Cognitive Level: Application REF: p. 340 OBJ: 6
TOP: Delirium KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

12. When admitting a patient who has recently become confused, the nurse asks the family for a list of all the medications that the patient is currently taking. Which medication identified by the family should the nurse be aware could be causing confusion?
a. Amoxicillin
b. Acetaminophen
c. Furosemide
d. Digoxin
ANS: D
Drugs that most commonly cause confusion include anticholinergics, digoxin, histamine-2 receptor blockers, benzodiazepines, nonsteroidal antiinflammatory drugs, and many antiarrhythmic and antihypertensive medications.

DIF: Cognitive Level: Comprehension REF: p. 337 | p. 339
OBJ: 3 TOP: Confusion Due to Medications
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

13. A patient has been admitted with a diagnosis of confusion. The physicians admission note states that he wants to assess for delirium versus dementia. What should the nurse be aware that the main differences include?
a. Whereas delirium usually lasts several years, dementia lasts only a few days.
b. Whereas delirium usually has sudden onset and is reversible, dementia is chronic and irreversible.
c. Whereas dementia is usually caused by medications, delirium is not.
d. Whereas dementia is easily treated with reality orientation, delirium is not.
ANS: B
Delirium is a short-term, confusional state that has a sudden onset and is typically reversible. Dementia is a syndrome that is often chronic and irreversible.

DIF: Cognitive Level: Knowledge REF: p. 340 OBJ: 4
TOP: Delirium versus Dementia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Psychosocial Adaptation

14. A nurse has found a patient with delirium in other patients rooms several times. What is the best action by the nurse?
a. Firmly tell the patient that he must stay out of other patients rooms and tell him to return to his room.
b. Take him back to his room and put him in bed with the side rails up.
c. Take him to the nurses station and let him visit for a while.
d. Administer a dose of lorazepam (Ativan) as ordered.
ANS: C
Avoid using physical restraints, which tend to increase anxiety and agitation. Sitting at the nurses station will allow the nurses to monitor his activity and frequently orient him to his surroundings.

DIF: Cognitive Level: Application REF: p. 342 OBJ: 6
TOP: Delirium KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

15. A nurse in a long-term care facility is taking patients to the dining room for lunch. She asks the patient who has been diagnosed with delirium if she is ready to go eat lunch. The patient does not respond. What should be the nurses next action?
a. Take the patient by the arm and lead her to the dining room.
b. Assist the patient to bed and bring her lunch to her.
c. Tell the patient that she can go to the dining room whenever she gets hungry.
d. Ask the patient again if she is ready to go eat lunch.
ANS: D
A patient with delirium may have difficulty focusing or paying attention, and questions must often be repeated several times.

DIF: Cognitive Level: Application REF: p. 336 | p. 340
OBJ: 6 TOP: Communication
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

16. A patient asks a nurse what causes dementia. What two most prevalent types of dementia should the nurse consider before responding?
a. Pick disease and Huntington disease
b. Alzheimer disease and vascular dementia
c. Creutzfeldt-Jakob disease and Pick disease
d. Vascular dementia and Huntington disease
ANS: B
Alzheimer disease and vascular dementia are the two most prevalent types of dementia.

DIF: Cognitive Level: Knowledge REF: p. 338 OBJ: 2
TOP: Types of Dementia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Psychosocial Adaptation

17. A nurse is assessing a patient for delirium versus dementia. What should the nurse expect the patient with dementia to display?
a. Intermittent fear affect
b. Perplexity affect
c. Bewilderment affect
d. Flat affect
ANS: D
The patient with dementia will have a flat or indifferent affect. The other three choices would be presented by a patient with delirium.

DIF: Cognitive Level: Comprehension REF: p. 339 OBJ: 4
TOP: Dementia Affect KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

18. A nurse is taking a patient who has Alzheimer disease to the bathing room for a tub bath. The patient states, Please dont make me take a bath today. I am so afraid that I will be washed down the drain. What is the nurses best response?
a. Dont be silly; theres no way you would fit in the drain.
b. I am your nurse, and I will stay with you, so you shouldnt be afraid of your bath.
c. Lets go back to your room, and I will bathe you there.
d. Today is your day for a bath.
ANS: C
The nurse should recognize irrational fears and arrange alternative ways to give personal care.

DIF: Cognitive Level: Application REF: p. 344-345 OBJ: 6
TOP: Alzheimer Disease KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

19. Which characteristics are most likely to be present in the patient with dementia?
a. Forgets things relatively quickly and is usually unable to learn new things
b. Can remember new tasks but will forget any previously taught tasks
c. Cannot learn new information but will probably remember anything you ask about the past
d. Responds well to reality orientation and needs to have a flexible schedule
ANS: A
Keeping in mind the following two important concepts when taking care of patients with dementia is helpful: (1) they usually forget things relatively quickly, and (2) they are usually unable to learn new things.

DIF: Cognitive Level: Comprehension REF: p. 344 OBJ: 1 | 4
TOP: Dementia KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

20. A patient is displaying confusion, which began very suddenly and lasted less than 1 week. What should the nurse suspect is present?
a. Dementia
b. Acute confusion
c. Symptoms of Huntington disease
d. Senile dementia
ANS: B
Acute confusion begins abruptly and generally lasts a short period. It usually lasts 1 week and rarely lasts longer than 1 month.

DIF: Cognitive Level: Comprehension REF: p. 340 OBJ: 2
TOP: Acute Confusion KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

21. A nurse is preparing a room for a patient being transferred from the emergency department with a diagnosis of delirium. What should the nurse ensure in regard to the room?
a. Brightly lit
b. Shared by another patient
c. Visible from the nurses station
d. Dark and quiet
ANS: C
The patient should be in a private room with continual supervision. The room should be quiet and uncluttered, and lighting should be soft and diffuse to avoid shadows.

DIF: Cognitive Level: Comprehension REF: p. 340 OBJ: 6
TOP: Environmental Consideration KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

22. A nurse caring for a patient with dementia notices that the patient stays awake most of the night. What is the nurses most appropriate action?
a. Give a prescribed sleeping medication.
b. Tell the patient that it is nighttime and that she must go to sleep.
c. Check the patients record to see whether she is sleeping during the day.
d. Put the patient to bed and put the side rails up.
ANS: C
Sleep and awakening are often reversed in patients with dementia. Trying to keep the patient awake during the day is helpful.

DIF: Cognitive Level: Application REF: p. 341 OBJ: 6
TOP: Sleep Patterns KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

23. A nurse is discussing home care of a patient with dementia with the patients family. What should the nurse advise the family do to prevent the patient from wandering?
a. Apply a vest restraint to keep the patient in bed or in a chair.
b. Put locks on any doors that it would be dangerous for the patient to open (e.g., outside doors, medicine cabinet).
c. Have someone remind the patient at least every 2 hours that he or she must not go outside by him or herself.
d. Set up a reward system for the times the patient stays where the family has requested.
ANS: B
Patients with dementia must have the environment adapted to them rather than trying to adapt the patient to the environment. They usually forget things relatively quickly and will probably not remember what you have told them.

DIF: Cognitive Level: Application REF: p. 344-345 OBJ: 6
TOP: Wandering KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

24. A patient asks a nurse, My doctor says I get confused sometimes because I have vascular dementia. What caused me to have that? What is the most appropriate response by the nurse?
a. It is usually caused from damage to brain cells because of inadequate blood supply, like a small stroke.
b. It is probably just some abnormal electrical activity in your brain.
c. You probably have a brain tumor.
d. Im sure he will explain it to you later.
ANS: A
Patients with vascular dementia often have had a series of small strokes that cause progressive damage.

DIF: Cognitive Level: Knowledge REF: p. 338-339 OBJ: 1
TOP: Vascular Dementia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

25. What should nursing care focus on to best support a patient with mild cognitive impairment (MCI)?
a. Reorienting the patient to the physical environment
b. Developing strategies to improve memory
c. Assisting with dressing and eating
d. Establishing toileting schedules
ANS: B
Persons with MCI need strategies for improving their memory. These persons have memory impairment but have otherwise normal cognition.

DIF: Cognitive Level: Comprehension REF: p. 338 OBJ: 1 | 6
TOP: MCI KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

26. An 80-year-old patient with delirium related to high fever is hallucinating about large animals being in the room. What is the most reassuring nursing response to this patient?
a. Yes, the animals are in here, but they are sound asleep.
b. Im going to turn out the lights so you wont have to look at the animals.
c. You are in the hospital. There are no animals in this room.
d. The hospital does not allow animals in the room.
ANS: C
Reorientation and presentation of reality are helpful with patients who have delirium.

DIF: Cognitive Level: Application REF: p. 340 OBJ: 6
TOP: Hallucinations KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

MULTIPLE RESPONSE

27. What are believed to be causes of Alzheimer disease? (Select all that apply.)
a. Amyloid deposits in the brain
b. Excess of acetylcholine
c. Neurofibrillary tangles
d. Infiltration of Lewy bodies
e. Series of small strokes
ANS: A, C
The cause of Alzheimer disease is still unclear, but protein deposits of amyloid have been found during autopsies of the brains of patients with Alzheimer disease, as well as tangled neurofibers. In addition, a deficiency of acetylcholine exists. Lewy bodies are associated with another type of dementia, and small strokes are thought to be the cause of vascular dementia.

DIF: Cognitive Level: Knowledge REF: p. 339 OBJ: 2
TOP: Etiology of Alzheimer Disease KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

COMPLETION

28. When a normally oriented 87-year-old resident in a long-term care facility exhibits acute confusion, the nurse should first assess for a(n) _____.

ANS:
infection
Infections, especially those that cause fever, can result in an older patient becoming confused or delirious.

DIF: Cognitive Level: Application REF: p. 336 OBJ: 3
TOP: Infections as Cause of Acute Confusion
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

OTHER

29. An 80-year-old woman who has Alzheimer disease is restless, wanders during mealtimes, and will not sit down to eat. The nurse assisting with writing the care plan prioritizes the following interventions for the goal: The patient will eat at least 25% of each meal. (Prioritize the options in sequence, from the most therapeutic to the least therapeutic. Separate letters by a comma and space as follows: A, B, C, D.)
A. Place her in a chair with a vest restraint.
B. Assign a nursing assistant (NA) to feed her.
C. Give her a high-protein drink in a small cup to carry with her.
D. Offer peanut butter crackers as she passes by.
E. Leave her alone. She will eat when she is hungry.

ANS:
C, D, B, A, E
Offering a high-energy drink in a small cup partially meets the goal without further agitating the patient. Offering a cracker accomplishes the same thing, but accurate evaluation of whether the crackers are eaten or just dropped might be difficult. Assigning an NA to feed her may agitate her further and reduce her intake even more; in addition, it may not be the best use of available personnel. Placing her in a chair with a vest restraint is not a very desirable intervention and may not encourage her to eat. Leaving her alone does not meet the goal nor does it reduce the nutrition deficit.

DIF: Cognitive Level: Analysis REF: p. 344-345 OBJ: 6
TOP: Nutrition Deficit KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

30. An older adult long-term care resident with dementia becomes agitated each evening after supper because he has not walked his dog. The nurse plans to intervene by doing the following: (Prioritize these options from the most therapeutic to the least therapeutic. Separate letters by a comma and space as follows: A, B, C, D.)
A. Remind him that his dog is not in the facility.
B. Help him draw a dog on paper and carry it with him.
C. Give him a small stuffed dog.
D. Reorient the resident to the time and place.
E. Ask his daughter to bring the dog to the facility.

ANS:
D, A, C, B, E
Reorienting the resident is the most simple and possibly the most helpful intervention. Reminding him that no dog is in the facility reorients him to place. Giving him a small dog may distract him, satisfy his need for a dog, and is simpler than attempting to get him to concentrate on drawing while he is agitated. Involving a family member is good, but family cannot always arrange to be on hand on a daily basis at a specific time.

DIF: Cognitive Level: Analysis REF: p. 344-345 OBJ: 6
TOP: Confusion with Agitation KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

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