🧠 DEMENTIA
An older adult has gradually worsening memory, difficulty managing finances, and increasing dependence with ADLs over the past 2 years. This pattern is most consistent with this cognitive disorder.
What is dementia (major neurocognitive disorder)?
This feature most clearly distinguishes delirium from dementia.
What is an acute onset with fluctuating cognition and impaired attention?
Hearing voices when no external stimulus is present is classified as this symptom.
What is an auditory hallucination?
Donepezil is prescribed for a client with Alzheimer's disease for this purpose.
What is to help slow cognitive decline/manage symptoms rather than cure the disease?
A confused hospitalized client repeatedly asks where they are. This simple nursing intervention can decrease anxiety and promote orientation.
What is frequent, calm reorientation using clocks, calendars, familiar objects, and consistent communication?
A client with dementia repeatedly asks, “When is my husband coming to get me?” Her husband died several years ago. This nursing response is most therapeutic.
What is acknowledge the emotion and redirect rather than repeatedly correcting the client?
An 82-year-old hospitalized client becomes confused after surgery and is pulling at the IV. Before assuming the client has dementia, the nurse should recognize the change as this until proven otherwise.
What is delirium?
A client with schizophrenia says, “I know the staff are putting something in my food to poison me.” The nurse recognizes this statement as which type of symptom?
What is a persecutory delusion?
A client recently started donepezil. Which report should the nurse recognize as a common adverse effect requiring further assessment: “I have had nausea and diarrhea for several days” or “My mouth feels dry”?
What is nausea and diarrhea?
A client with schizophrenia says, “There are spiders crawling all over that wall!” The nurse sees no spiders. The most therapeutic response should accomplish these two things.
What is acknowledge the client's experience while presenting reality?
“I understand that you see spiders and that must be frightening. I do not see them.”
A hospitalized client with moderate dementia becomes increasingly restless every evening, attempts to leave the room, and says, “I need to go home before it gets dark.” This phenomenon may explain the behavior.
What is sundowning?
A hospitalized older adult who was alert yesterday is now disoriented, pulling at the IV, and unable to maintain attention during conversation. Which information should the nurse obtain first from the medical record?
What are recent changes in medications, laboratory values, vital signs, oxygenation, and evidence of infection?
A client says, “The voices are telling me that I deserve to die.” The nurse's next question should assess this.
What is whether the voices are commanding the client to harm self or others and whether the client intends to act on them?
A client taking haloperidol develops neck spasms, jaw tightness, and upward deviation of the eyes. The nurse recognizes this adverse effect.
What is acute dystonia, an extrapyramidal symptom (EPS)?
A client with dementia repeatedly attempts to leave the unit saying, “My children are waiting for me at school.” Which nursing action is preferable to arguing about the client's children's ages?
What is validate the emotion and redirect the client to a safe activity?
A client with dementia suddenly becomes much more confused, cannot maintain attention, and develops urinary incontinence and a temperature of 38.4°C (101.1°F). The nurse's priority is this.
What is assess for an acute underlying cause such as infection/delirium?
A client develops acute confusion. Assessment reveals SpO₂ 86%, temperature 38.7°C (101.7°F), and BP 88/54. Rather than repeatedly reorienting the client, the nurse's priority is this.
What is address the physiologic instability and identify/treat the underlying cause?
A client states, “The FBI put a transmitter in my tooth.” Which approach should the nurse use when responding?
What is acknowledge the client's feelings, present reality, and avoid arguing with or reinforcing the delusion?
“That sounds frightening. I don't see evidence that the FBI is monitoring you, but I understand that this feels very real to you.”
A client taking an antipsychotic develops a temperature of 103°F, severe muscle rigidity, diaphoresis, altered mental status, and unstable blood pressure. The nurse suspects this life-threatening condition.
What is neuroleptic malignant syndrome (NMS)?
Four clients require assessment. Which should the nurse see first?
A. Client with dementia who cannot remember breakfast
B. Client with schizophrenia who refuses a recreational activity
C. Client with delirium who has new restlessness, RR 30/min, and SpO₂ 87%
D. Client taking donepezil who reports mild nausea
Who is Client C?
Acute cognitive change plus respiratory compromise = priority. Use ABCs rather than focusing only on the psychiatric/cognitive diagnosis.
A client with advanced dementia is pacing, pulling at clothing, grimacing, and striking staff during care. The client cannot reliably describe symptoms. Before requesting a sedating medication, the nurse should prioritize this assessment.
What is assess for pain and other unmet physiologic needs?
A client with delirium repeatedly attempts to climb out of bed. Which nursing action should be attempted first?
What is identify and address physiologic/environmental causes while implementing least-restrictive safety measures?
pain? hypoxia? urinary retention? infection? unfamiliar surroundings? toileting? medication?
A client with schizophrenia says, “The voices aren't as loud anymore.” Later, the nurse observes the client staring toward the ceiling and quietly saying, “Leave me alone.” What should the nurse conclude?
What is the client may still be experiencing auditory hallucinations and requires further assessment?
A client taking clozapine calls the clinic reporting fever, chills, and a severe sore throat. The nurse should instruct the client to seek prompt evaluation because of concern for this adverse effect.
What is severe neutropenia/agranulocytosis?
Infection symptoms in a client taking clozapine require prompt evaluation and review of the ANC.
A client with schizophrenia suddenly stops talking during the interview, looks toward the corner, and whispers, “No, I won't do it.” The nurse should take this action before continuing the mental-status examination.
What is assess immediately for command hallucinations and risk of harm to self or others?