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.
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
3. While a nurse is dressing a patient who has dementia as a result of Huntington disease, the
patient states, “I don’t want to wear clothes today” and begins to resist help putting on her
clothes. What is the nurse’s 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.
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.
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 didn’t 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.”
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.
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
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 patient’s clothes on without assistance from the patient.
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
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
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.
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
13. A patient has been admitted with a diagnosis of confusion. The physician’s 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.
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.
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 nurse’s 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.
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
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
18. A nurse is taking a patient who has Alzheimer disease to the bathing room for a tub bath. The
patient states, “Please don’t make me take a bath today. I am so afraid that I will be washed
down the drain.” What is the nurse’s best response?
a.
“Don’t be silly; there’s no way you would fit in the drain.”
b.
“I am your nurse, and I will stay with you, so you shouldn’t be afraid of your
bath.”
c.
“Let’s go back to your room, and I will bathe you there.”
d.
“Today is your day for a bath.”
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
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
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
22. A nurse caring for a patient with dementia notices that the patient stays awake most of the
night. What is the nurse’s 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 patient’s record to see whether she is sleeping during the day.
d.
Put the patient to bed and put the side rails up.
23. A nurse is discussing home care of a patient with dementia with the patient’s 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.
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.
“I’m sure he will explain it to you later.”
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
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.
“I’m going to turn out the lights so you won’t 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.”
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
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) _____.
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.
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.