Dementia
A patient with moderate dementia repeatedly asks where her husband is despite being told he died 10 years ago. The most therapeutic response avoids this communication technique.
What is reality confrontation?
A patient becomes acutely confused, hallucinating, and unable to maintain attention 48 hours after surgery. The nurse's priority action is:
What is assess for an underlying physiological cause?
The patient states, "The television anchor is speaking directly to me." This symptom is:
What is a delusion of reference?
A patient alternates between praising one nurse and criticizing another. This defense mechanism is:
What is splitting?
A nurse caring for a patient hearing voices should first determine:
What are the content of the hallucinations and potential safety risks?
The nurse notes worsening confusion, agitation, and wandering beginning around 1800 daily in a patient with dementia. This phenomenon is known as:
What is sundowning?
The hallmark assessment finding that most clearly differentiates delirium from dementia.
What is fluctuating level of consciousness and impaired attention?
The nurse enters a room and finds a patient motionless, staring at the ceiling for several hours. This manifestation is most consistent with:
What is catatonia?
A patient repeatedly threatens self-harm when staff attempt to enforce limits. The most appropriate nursing intervention is:
What is consistent limit-setting?
A patient with dementia becomes combative during care. The nurse's best initial intervention is:
What is assess for an unmet need or environmental trigger?
A patient with dementia becomes agitated when assisted with bathing. The priority nursing intervention is based on this principle.
What is identifying and reducing triggers for behavioral symptoms?
An elderly patient suddenly becomes confused. The nurse should suspect this condition until proven otherwise.
What is delirium?
A patient reports hearing voices commanding him to harm another patient. The nurse's immediate priority is:
What is ensuring safety?
The personality disorder most strongly associated with fear of abandonment and unstable interpersonal relationships.
What is Borderline Personality Disorder?
The nurse is caring for a patient with schizophrenia who suddenly becomes mute and refuses to move. This represents:
What is catatonic behavior?
A patient with advanced dementia can no longer sequence the steps needed to brush their teeth. This cognitive deficit is called:
What is apraxia?
The nurse receives report on four patients. Which patient should be assessed first?
Who is the patient experiencing delirium?
The symptom most associated with poor long-term functional outcomes in schizophrenia.
What are negative symptoms?
A patient believes coworkers are constantly plotting against him despite lack of evidence. The nurse suspects:
What is Paranoid Personality Disorder?
A patient with delirium attempts to climb out of bed and remove oxygen tubing. The nurse should implement:
What are immediate safety interventions and assessment of the cause?
The nurse recognizes this as the greatest safety concern when caring for a patient with moderate-stage dementia who frequently attempts to leave the unit.
What is risk for wandering and elopement?
An older adult presents with acute confusion, visual hallucinations, fever, and dysuria. The nurse recognizes the confusion is most likely caused by:
What is a urinary tract infection?
A patient states, "The CIA implanted a transmitter in my brain and now controls my thoughts." The nurse identifies this as:
What is a persecutory delusion with thought control?
A patient displays grandiosity, entitlement, and a lack of empathy. This personality disorder is:
What is Narcissistic Personality Disorder?
The nurse receives these reports. Which patient should be seen first?
Who is the patient experiencing command hallucinations?