Question: A patient diagnosed with dementia no longer recognizes family members. The family asks how long it will be before their family member recognizes them when they visit. What is the nurse’s best reply?
Answer Options:
Answer: d. “It is disappointing when someone you love no longer recognizes you.”
Question: A patient diagnosed with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members?
Answer Options:
Answer: b. Focus interaction on familiar topics.
Question: What is the priority nursing need for a patient diagnosed with late-stage dementia?
Answer Options:
Answer: c. Maintenance of nutrition and hydration
Question: Which nursing intervention is appropriate to use for patients diagnosed with either delirium or dementia?
Answer Options:
Answer: c. Reintroduce the health care worker at each contact.
Question: A hospitalized patient experiencing delirium misinterprets stimuli and a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios?
Answer Options:
Answer: a. Patient will remain safe in the environment.
Question: A patient diagnosed with moderate to severe Alzheimer’s disease has a dressing and grooming self-care deficit. Designate the appropriate interventions to include in the patient’s plan of care. (Select all that apply.)
Answer: a. Provide clothing with elastic and hook-and-loop closures.
Question: Which assessment findings would the nurse expect in a patient experiencing delirium? (Select all that apply.)
Answer Options:
Answer: a. Impaired level of consciousness b. Disorientation to place and time c. Wandering attention
Question: A nurse should anticipate that which symptoms of Alzheimer’s disease will become apparent as the disease progresses from stage 3, moderate to severe to stage 4, late stage? (Select all that apply.)
Answer Options:
Answer: a. Agrapahia b. Hyperorality d. Hypermotamorphosis
Question: A patient with a history of daily alcohol abuse was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak?
Answer Options:
Answer: b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped)
Question: A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who presents with what related characteristic?
Answer Options:
Answer: d. Facial abnormalities and growth retardation
Question: A patient was admitted 1 day ago with a hip fracture sustained in a fall while intoxicated. The patient points to the Buck’s traction and screams, “Somebody tied me up with ropes.” The patient’s response is described by what term?
Answer Options:
Answer: a. An illusion
Question: A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats/min. The patient shouts, “Snakes are crawling on my bed. I’ve got to get out of here.” What is the most accurate assessment of the situation?
Answer Options:
Answer: c. The patient has symptoms of alcohol withdrawal delirium.
Question: A patient admitted yesterday for injuries sustained in a fall while intoxicated believes snakes are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis?
Answer Options:
Answer: d. Risk for injury
Question: A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse anticipate the health care provider will prescribe?
Answer Options:
Answer: c. Benzodiazepine, such as lorazepam
Question: A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority?
Answer Options:
Answer: c. Provide one-on-one supervision.
Question: A patient with a history of daily alcohol use says, “Drinking helps me cope with being a single parent.” Which response by the nurse would help the individual conceptualize the drinking more objectively?
Answer Options:
Answer: d. “Tell me what happened the last time you drank.”
Question: A patient asks for information about the goals of Alcoholics Anonymous (AA). Which is the nurse’s best response?
Answer Options:
Answer: a. “It is a self-help group with the goal of sobriety.”