A
A 59-yr-old female patient with a frontotemporal lobar dementia has difficulty with verbal expression. While her husband was at work, she walked to the gas station for a soda but did not understand the request for payment. What can the nurse suggest to keep the patient safe?
a. Adult day care
b. Assisted living
c. Advance directives
d. Monitor for behavioral changes
a. adult day care
Rationale: To keep the patient safe during the day while the husband is at work, an adult day care facility would be the best choice. This patient would not need assisted living. Advance directives are important but are not related to her safety. Monitoring for behavioral changes will not keep her safe during the day.
Which nursing intervention is most appropriate when caring for patients with dementia?
a. Avoid direct eye contact.
b. Lovingly call the patient “honey” or “sweetie.”
c. Give simple directions, focusing on one thing at a time.
d. Treat the patient according to their age-related behavior
c. Give simple directions, focusing on one thing at a time.
Rationale: When dealing with patients with dementia, tasks should be simplified, giving directions using gestures or pictures and focusing on one thing at a time. It is best to treat these patients as adults, with respect and dignity, even when their behavior is childlike. The nurse should use gentle touch and direct eye contact. Calling the patient “honey” or “sweetie” can be condescending and does not show respect.
A 78-yr-old woman was transferred to the intensive care unit after emergency abdominal surgery. The nurse notes the patient is disoriented and confused, has incoherent speech, is restless, and agitated. Which action by the nurse is most appropriate?
a. Reorient the patient.
b. Document the findings.
c. Notify the health care provider.
d. Administer lorazepam (Ativan)
a. Reorient the patient
Rationale: The patient has manifestations of delirium. Care of the patient with delirium is focused on eliminating precipitating factors and protecting the patient from harm. Give priority to creating a calm and safe environment. The nurse should stay at the bedside and provide reassurance and reorienting information as to place, time, and procedures. The nurse should reduce environmental stimuli, including noise and light levels. Avoid the use of chemical and physical restraints if possible.
Benzodiazepines are indicated in the treatment of delirium caused by which condition?
a. Polypharmacy
b. Cerebral hypoxia
c. Alcohol withdrawal
d. Electrolyte imbalances
c. Alcohol withdrawal
Rationale: Benzodiazepines can be used to treat delirium associated with sedative and alcohol withdrawal. However, these drugs may worsen delirium caused by other factors and must be used cautiously. Polypharmacy, cerebral hypoxia, and electrolyte imbalances are not treated with benzodiazepines.
The nurse has administered a dose of risperidone (Risperdal) to a patient with delirium. What finding demonstrates the intended effect of the medication?
a. Lying quietly in bed
b. Alleviation of depression
c. Reduction in blood pressure
d. Disappearance of confusion
a. Lying quietly in bed
Rationale: Risperidone is an antipsychotic drug that reduces agitation and produces a restful state in patients with delirium. However, it should be used with caution. Antidepressant medications treat depression, and antihypertensive medications treat hypertension. However, there are no medications that will cause confusion to disappear in a patient with delirium.
The nurse in the long-term care facility cares for a 70-yr-old man with late-stage dementia who is undernourished and has problems chewing and swallowing. What should the nurse include in the plan of care for this patient?
a. Limit fluid intake during mealtimes to prevent aspiration.
b. Turn on the television to provide a distraction during meals.
c. Provide thickened fluids and moist foods in bite-size pieces.
d. Allow the patient to select favorite foods from the menu choices
c. Provide thickened fluids and moist foods in bite-sized pieces
Rationale: If patients with dementia have problems chewing or swallowing, pureed foods, thickened liquids, and nutritional supplements should be provided. Foods that are easy to swallow are moist and should be in bite-size pieces. Distractions at mealtimes, including the television, should be avoided. Fluids should not be limited but offered frequently; fluids should be thickened. Patients with late-stage dementia have difficulty understanding words and would not have the cognitive ability to select menu choices.
Which patient should receive a depression assessment first?
a. A patient in the early stages of Alzheimer’s disease
b. A patient who is in the final stage of Alzheimer’s disease
c. A patient experiencing delirium secondary to dehydration
d. A patient who has become delirious following an atypical drug response
a. A patient in the early stages of Alzheimer's disease
Rationale: Patients in the early stages of Alzheimer’s disease are particularly susceptible to depression because they are acutely aware of their cognitive changes and the expected disease trajectory. Delirium is typically a short-term health problem that does not typically pose a heightened risk of depression.
A patient is diagnosed with the mild cognitive impairment stage of Alzheimer’s disease. What nursing intervention is most appropriate for the nurse use with the patient?
a. Communicate using a letter or picture board.
b. Treat disruptive behavior with antipsychotic drugs.
c. Use a calendar and family pictures as memory aids.
d. Apply a wander guard mechanism to keep the patient in the area
c. Use a calendar and family pictures as memory aids
Rationale: The patient with mild cognitive impairment will have problems with memory, language, or another essential cognitive function that is severe enough to be noticeable to others but does not interfere with activities of daily living. A calendar and family pictures for memory aids will help this patient. This patient should not yet have disruptive behavior or get lost easily. Using a writing board will not help this patient with communication.
When caring for a patient with Alzheimer’s disease, which task could be delegated to the LPN/VN on the team?
a. Administer enteral feedings via a gastrostomy tube.
b. Teach patient and caregivers memory enhancement aids.
c. Use bed alarms and frequent monitoring to decrease fall risk.
d. Make referrals for community services such as adult day care.
a. Administer enteral feedings via a gastrostomy tube
Rationale: Administering enteral feedings via a gastrostomy tube is within the scope of practice for the LPN/VN. The RN will be responsible for individualized teaching and patient referrals. The UAP will be able to use bed alarms and frequently monitor the patient.
Which patient has the greatest risk of developing delirium?
a. An older patient whose recent CT scan shows brain atrophy.
b. A patient with fibromyalgia whose chronic pain has worsened.
c. A patient with a fracture who spent the night in the emergency department.
d. An older patient who takes multiple medications to treat various health problems
d. An older patient who takes multiple medications to treat various health problems
Rationale: Polypharmacy is implicated in many cases of delirium, and this phenomenon is especially common among older adults. Brain atrophy, if associated with cognitive changes, is indicative of dementia. Alterations in sleep and environment, as well as pain, may cause delirium, but this is less of a risk than in an older adult who takes multiple medications.
Which statement by the wife of a patient with Alzheimer’s disease demonstrates an accurate understanding of her husband’s medication regimen?
a. “I’m really hoping his medications will slow down his mental losses.”
b. “We’re both holding out hope that this medication will cure his disease.”
c. “The medications might prevent a bodily decline while he declines mentally.”
d. “If we follow his medication schedule, he may not have any physical effects of his disease.”
a. "I'm really hoping his medications will slow down his mental losses."
Rationale: There is presently no cure for AD, and drug therapy aims at improving or controlling decline in cognition. Medications do not directly address the physical manifestations of AD.
Unlicensed assistive personnel (UAP) working for a home care agency report a change in the alertness and language of an 82-yr-old female patient. The home care nurse plans a visit to evaluate the patient’s cognitive function. Which assessment would be most appropriate?
a. Glasgow Coma Scale (GCS)
b. Confusion Assessment Method (CAM)
c. Mini-Mental State Examination (MMSE)
d. National Institutes of Health Stroke Scale (NIHSS)
c. Mini-Mental State Examination (MMSE)
Rationale: The MMSE is often used to assess cognitive function. Cognitive testing is focused on evaluating memory, ability to calculate, language, visual-spatial skills, and degree of alertness. The CAM is used to assess for delirium. The GCS is used to assess the degree of impaired consciousness. The NIHSS is a neurologic examination stroke scale used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss.
The home care nurse is visiting patients in the community. Which patient is exhibiting an early warning sign of Alzheimer’s disease (AD)?
a. A 65-yr-old male patient does not recognize his family members and close friends
b. A 59-yr-old female patient misplaces her purse and jokes about having memory loss
c. A 79-yr-old male patient is incontinent and not able to perform hygiene independently.
d. A 72-yr-old female patient is unable to locate the address where she has lived for 10 years
d. A 72-yr-old female patient is unable to locate the address where she has lived for 10 years
Rationale: An early warning sign of AD is disorientation to time and place such as geographic disorientation. Occasionally misplacing items and joking about memory loss are examples of normal forgetfulness. Impaired ability to recognize family and close friends is a manifestation of middle or moderate dementia (or AD). Incontinence and inability to perform self-care activities occur with severe or late dementia (or AD).
When administering the Mini-Cog exam to a patient with possible Alzheimer’s disease, which action will the nurse take?
a. Check the patient’s orientation to time and date.
b. Obtain a list of the patient’s prescribed medications.
c. Ask the person to use a clock drawing to indicate a specific time.
d. Determine the patient’s ability to recognize a common object such as a pen
c. Ask the person to use a clock drawing to indicate a specific time
Rationale: In the Mini-Cog, patients illustrate a specific time stated by the examiner by drawing the time on a clock face. The other actions may be included in assessment for Alzheimer’s disease but are not part of the Mini-Cog exam
The nurse’s initial action for a patient with moderate dementia who develops increased restlessness and agitation should be to
a. reorient the patient to time, place, and person.
b. administer a PRN dose of lorazepam (Ativan).
c. assess for factors that might be causing discomfort.
d. assign unlicensed assistive personnel (UAP) to stay in the patient’s room
c. Assess for factors that might be causing discomfort
Rationale: Increased motor activity in a patient with dementia is frequently the patient’s only way of responding to factors such as pain, so the nurse’s initial action should be to assess the patient for any precipitating factors. Administration of sedative drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia. Assigning UAP to stay with the patient may also be necessary, but any physical changes that may be causing the agitation should be addressed first.
The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which action should the nurse take?
a. Have the patient take a mid-morning nap.
b. Keep window blinds open during the day.
c. Provide hourly orientation to time and place.
d. Move the patient to a quiet room in the afternoon
b. Keep window blinds open during the day
Rationale: A likely cause of sundowning is a disruption in circadian rhythms, and keeping the patient active and in daylight will help reestablish a more normal circadian pattern. Moving the patient to a different room might increase confusion. Taking a nap will interfere with nighttime sleep. Hourly orientation will not be helpful in a patient with dementia
A patient is being evaluated for Alzheimer’s disease (AD). The nurse explains to the patient’s adult children that:
a. the most important risk factor for AD is a family history of the disorder.
b. a diagnosis of AD is made only after other causes of dementia are ruled out.
c. new drugs have been shown to reverse AD deterioration dramatically in some
patients.
d. brain atrophy detected by magnetic resonance imaging (MRI) would confirm the
b. A diagnosis of AD is made only after other causes of dementia are ruled out
Rationale: The diagnosis of AD is usually one of exclusion. Age is the most important risk factor for development of AD. Drugs may slow the deterioration but do not reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in other diseases as well and does not confirm a diagnosis of AD
Which action will help the nurse determine whether a new patient’s confusion is caused by dementia or delirium?
a. Ask about a family history of dementia.
b. Administer the Mini-Mental Status Exam.
c. Use the Confusion Assessment Method tool.
d. Obtain a list of the patient’s usual medications
c. Use the Confusion Assessment Method Tool
Rationale: The Confusion Assessment Method tool has been extensively tested in assessing delirium. The other actions will be helpful in determining cognitive function or risk factors for dementia or delirium, but they will not be useful in differentiating between dementia and delirium
A patient seen in the outpatient clinic is diagnosed with mild cognitive impairment (MCI). Which action will the nurse include in the plan of care?
a. Suggest a move into an assisted living facility.
b. Schedule the patient for more frequent appointments.
c. Ask family members to supervise the patient’s daily activities.
d. Discuss the preventive use of acetylcholinesterase medications
b. Schedule the patient for more frequent appointments
Rationale: Ongoing monitoring is recommended for patients with MCI. MCI does not usually interfere with activities of daily living, acetylcholinesterase drugs are not used for MCI, and an assisted living facility is not indicated for a patient with MCI
The nurse is concerned about a postoperative patient’s risk for injury during an episode of delirium. The most appropriate action by the nurse is to
a. secure the patient in bed using a soft chest restraint.
b. ask the health care provider to order an antipsychotic drug.
c. instruct family members to remain at the patient’s bedside and prevent injury.
d. assign unlicensed assistive personnel (UAP) to stay with and reorient the patient.
d. Assign unlicensed assistive personnel (UAP) to stay with and reorient the patient
Rationale: The priority goal is to protect the patient from harm. Having a UAP stay with the patient will ensure the patient’s safety. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have many side effects. Restraints are not recommended because they can increase the patient’s agitation and disorientation.
When providing community health care teaching about the early warning signs of Alzheimer’s disease (AD), which signs should the nurse ask family members to report? (Select all that apply.)
a. Misplacing car keys
b. Losing sense of time
c. Difficulty performing familiar tasks
d. Problems with performing basic calculations
e. Momentarily forgets an acquaintance’s name
f. Becoming lost in a usually familiar environment
b. losing sense of time
c. difficulty performing familiar tasks
d. problems with performing basic calculations
f. becoming lost in a usually familiar environment
Rationale: Rationale: Difficulty performing familiar tasks, problems with performing basic calculations, losing sense of time, and becoming lost in a usually familiar environment are all part of the early warning signs of AD. Misplacing car keys and momentarily forgetting a name is a normal frustrating event for many people.
The patient is having some increased memory and language problems. What diagnostic tests will be done before this patient is diagnosed with Alzheimer’s disease? (Select all that apply.)
a. Urinalysis
b. Chest x-ray
c. MRI of the head
d. Liver function tests
e. Neuropsychologic testing
f. Blood urea nitrogen and serum creatinine
a. Urinalysis
c. MRI of the head
d. Liver function tests
e. Neuropsychologic testing
f. Blood urea nitrogen and serum creatinine
Rationale: Because there is no definitive diagnostic test for Alzheimer’s disease, and many conditions can cause manifestations of dementia, testing must be done to eliminate any other causes of cognitive impairment. These include urinalysis to eliminate a urinary tract infection, an MRI to eliminate brain tumors, liver function tests to eliminate encephalopathy, BUN and serum creatinine to rule out renal dysfunction, and neuropsychologic testing to assess cognitive function. A chest x-ray examination is not used to investigate an alternate cause of memory or language problems.
The spouse of a 67-yr-old male patient with early stage Alzheimer’s disease (AD) tells the nurse, “I am exhausted from worrying all the time. I don’t know what to do.” Which actions are best for the nurse to take next (select all that apply)?
a. Suggest that a long-term care facility be considered.
b. Offer ideas for ways to distract or redirect the patient.
c. Teach the spouse about adult day care as a possible respite.
d. Suggest that the spouse consult with the physician for antianxiety drugs.
e. Ask the spouse what she knows and has considered about dementia care options.
b. Offer ideas for ways to distract or redirect the patient
c. Teach the spouse about adult day care as a possible respite
e. Ask the spouse what she knows and has considered about dementia care options.
Rationale: The stress of being a caregiver can be managed with a multicomponent approach. This includes respite care, learning ways to manage challenging behaviors, and further assessment of what the spouse may already have considered for care options. The patient is in the early stages and does not need long-term placement. Antianxiety medications may be appropriate, but other measures should be tried first
Which actions could the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) who is part of the team caring for a patient with Alzheimer’s disease (select all that apply)?
a. Develop a plan to minimize difficult behavior.
b. Administer the prescribed memantine (Namenda).
c. Remove potential safety hazards from the patient’s environment.
d. Refer the patient and caregivers to appropriate community resources.
e. Help the patient and caregivers choose memory enhancement methods.
f. Evaluate the effectiveness of the prescribed enteral feedings on patient nutrition.
b. Administer the prescribed memantine
c. Remove potential safety hazards from the patient's environment
Rationale: LPN/LVN education and scope of practice includes medication administration and monitoring for environmental safety in stable patients. Planning of interventions such as ways to manage behavior or improve memory, referrals, and evaluation of the effectiveness of interventions require registered nurse (RN)–level education and scope of practice.
After reviewing the health record shown in the accompanying figure for a patient who has multiple risk factors for Alzheimer’s disease (AD), which topic will be most important for the nurse to discuss with the patient?
Patient's History: Age 58, history of closed head injury, mother died at age 68 of Alzheimer's disease
Habits: smokes 15 cigarettes daily, 1-2 glasses of wine weekly, rides a bike to and from work
Lab Results: total cholesterol 220mg/dL, high density lipoprotein 80 mg/dL, low density lipoprotein 103 mg/dL
a. tobacco use
b. family history
c. cholesterol level
d. head injury history
a. tobacco use
Rationale: Tobacco use is a modifiable risk factor for AD. The patient will not be able to modify the increased risk associated with family history of AD and past head injury. While the total cholesterol is borderline high, the high HDL indicates that no change is needed in cholesterol management