Question: Two patients in a residential care facility are diagnosed with dementia. One shouts to the other, “Move along, you’re blocking the road.” The other patient turns, shakes a fist, and shouts, “I know what you’re up to; you’re trying to steal my car.” What is the nurse’s best action?
Answer Choices: a. Administer one dose of an antipsychotic medication to both patients. b. Reinforce reality. Say to the patients, “Walk along in the hall. This is not a traffic intersection.” c. Separate and distract the patients. Take one to the day room and the other to an activities area. d. Step between the two patients and say, “Please quiet down. We do not allow violence here.”
Answer: c. Separate and distract the patients. Take one to the day room and the other to an activities area.
Question: An older adult patient in an intensive care unit is experiencing visual and auditory illusions. Which nursing intervention will be most helpful?
Answer Choices: a. Keep the room brightly lit at all times. b. Place personally meaningful objects in view. c. Place large clocks and calendars on the wall. d. Assess the patient’s use of glasses and hearing aids.
Answer: d. Assess the patient’s use of glasses and hearing aids.
Question: A patient diagnosed with stage 2 moderate Alzheimer’s disease calls the police saying, “An intruder is in my room!” The nurse helps the patient discover that the patient misinterpreted a reflection in the mirror. Which clinical phenomenon can be characterized using which term?
Answer Choices: a. Aphasia b. Apraxia c. Agnosia d. Hyperorality
Answer: c. Agnosia
Question: During morning care, an assistive personnel asks a patient diagnosed with dementia, “How was your night?” The patient replies, “It was lovely. I went out to dinner and a movie with my friend.” Which term applies to the patient’s response?
Answer Choices: a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium
Answer: b. Confabulation
Question: A patient diagnosed with Alzheimer’s disease wanders at night. Which action should the nurse recommend for a family to use in the home to enhance safety?
Answer Choices: a. Place throw rugs on tile or wooden floors. b. Place locks at the tops of doors. c. Encourage daytime napping. d. Obtain a bed with side rails.
Answer: b. Place locks at the tops of doors.
Question: Goals and desired outcomes for an older adult patient experiencing delirium caused by fever and dehydration will focus on which outcome?
Answer Choices: a. Returning to premorbid levels of function. b. Improving ability to cope with current problems. c. Demonstrating motor responses to noxious stimuli. d. Exerting control over responses to perceptual distortions.
Answer: a. Returning to premorbid levels of function.
Question: An older adult diagnosed with moderate-stage Alzheimer’s disease forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient’s family?
Answer Choices: a. Labeling the bathroom door. b. Taking the older adult to the bathroom hourly. c. Placing the older adult in disposable adult diapers. d. Making sure the older adult does not eat nonfood items.
Answer: a. Labeling the bathroom door.
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 Choices: a. “Your family member will never again be able to identify you.” b. “I think that is a question the health care provider should answer.” c. “One never knows. Consciousness fluctuates in persons with dementia.” d. “It is disappointing when someone you love no longer recognizes you.”
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 Choices: a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Strategically place large clocks and calendars.
Answer: b. Focus interaction on familiar topics.
Question: What is the priority nursing need for a patient diagnosed with late-stage dementia?
Answer Choices: a. Promotion of self-care activities b. Meaningful verbal communication c. Maintenance of nutrition and hydration d. Prevention of the patient from wandering
Answer: c. Maintenance of nutrition and hydration
Question: Which nursing intervention is appropriate to use for patients diagnosed with either delirium or dementia?
Answer Choices: a. Speak in a loud, firm voice. b. Touch the patient before speaking. c. Reintroduce the health care worker at each contact. d. When the patient becomes aggressive, use physical restraint instead of medication.
Answer: c. Reintroduce the health care worker at each contact.
Question: A hospitalized patient experiencing delirium misinterprets reality and a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios?
Answer Choices: a. Patient will remain safe in the environment. b. Patient will participate actively in self-care. c. Patient will communicate verbally. d. Patient will acknowledge reality.
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 Choices: a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patient’s name and name of the item. c. Administer antianxiety medication before bathing and dressing. d. Provide necessary items and direct the patient to proceed independently. e. If the patient resists, use distraction and then try again after a short interval.
Answer: a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patient’s name and name of the item. e. If the patient resists, use distraction and then try again after a short interval.
Question: Which assessment findings would the nurse expect in a patient experiencing delirium? (Select all that apply.)
Answer Choices: a. Impaired level of consciousness b. Disorientation to place and time c. Wandering attention d. Apathy e. Agnosia
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 Choices: a. Agraphia b. Hyperorality c. Fine motor tremors d. Hypermetamorphosis e. Improvement of memory
Answer: a. Agraphia b. Hyperorality d. Hypermetamorphosis
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 Choices: a. Between 0800 and 1000 today (6 to 8 hours after drinking stopped) b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) c. About 0200 on hospital day 3 (72 hours after drinking stopped) d. About 0200 on hospital day 4 (96 hours after drinking stopped)
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 Choices: a. Jaundice b. Dependent on alcohol c. Healthy but underweight d. Fetal alcohol syndrome
Answer: d. Fetal alcohol syndrome