Chapter 23: Neurocognitive Disorders MH

An older adult patient takes multiple medications daily. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of:

a. delirium

b. dementia

c. amnestic syndrome

d. Alzheimer's disease

D. delirium

Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimers disease, a type of dementia, is more

insidious. Amnestic syndrome involves memory impairment without other cognitive

problems.

A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs. Get them off!" Which problem is the patient experiencing?

a. aphasia

b. dystonia

c. tactile hallucinations

d. mnemonic disturbance

C. tactile hallucinations

The patient feels bugs crawling on both legs, even though no sensory stimulus is

actually present. This description meets the definition of a hallucination, a false

sensory perception. Tactile hallucinations may be part of the symptom constellation of

delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle

tonus. Mnemonic disturbance is associated with dementia rather than delirium.

A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response?

a. "No bugs are on your legs. You are having hallucinations."

b. "I will have someone stay here and brush off the bugs for you."

c. "Try to relax. The crawling sensation will go away sooner if you can relax."

d. "I don't see any bugs, but I can tell you are frightened. I will stay with you."

D. "I don't see any bugs, but I can tell you are frightened. I will stay with you."

What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?

a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment

b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks

c. Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations

d. Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations

A. risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and miperception of the environment

What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations?

a. distraction using sensory stimulation

b. careful observation and supervision

c. avoidance of physical contact

d. activation of the bed alarm

B. careful observation and supervision

Careful observation and supervision are of ultimate importance because an

appropriate outcome would be that the patient will remain safe and free from injury.

Physical contact during care cannot be avoided. Activating a bed alarm is only one

aspect of providing for the patients safety.

A patient diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this patient?

a. Provide a well-lit room without glare or shadows. Limit noise and stimulation.

b. Maintain soft lighting day and night. Keep a radio on low volume continuously.

c. Light the room brightly day and night. Awaken the patient hourly to assess mental status.

d. Keep the patient by the nurse's desk while awake. Provide rest periods in a room with a television on.

A. provide a well-lit room without glare or shadows. Limit noise and stimulation

Which assessment finding would be likely for a patient experiencing a hallucination? The patient:

a. looks at shadows on a wall and says, "I see scary faces."

b. states, "I feel bugs crawling on my legs and biting me."

c. reports telepathic messages from the television.

d. speaks in rhymes.

B. states, "I feel bugs crawling on my legs and biting me."

A hallucination is a false sensory perception occurring without a corresponding

sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The other incorrect options apply to thought

insertion and clang associations.

Consider these health problems: Lewy body disease, frontal-temporal lobar degeneration, and Huntington's disease. Which term unifies these problems?

a. cyclothymia

b. dementia

c. delirium

d. amnesia

B. dementia

The listed health problems are all forms of dementia.

Which medication prescribed to patients diagnosed with Alzheimer's disease antagonizes N-Methyl-D-Aspartate (NMDA) channels rather than cholinesterase?

a. Donepezil (Aricept)

b. Rivastigmine (Exelon)

c. Memantine (Namenda)

d. Galantamine (Razadyne)

C. Memantine (Namenda)

Memantine blocks the NMDA channels and is used in moderate-to-late stages of the

disease. Donepezil, rivastigmine, and galantamine are all cholinesterace inhibitors.

These drugs increase the availability of acetylcholine and are most often used to treat

mild-to-moderate Alzheimers disease.

An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident?

a. aphasia

b. apraxia

c. agnosia

d. anhedonia

C. agnosia

Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the

loss of language ability. Apraxia refers to the loss of purposeful movement.

Anhedonia refers to a loss of joy in life.

An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police intervened, they found that this adult was wearing a heavy coat and hat, even though it was July. Which stage of Alzheimer's disease is evident?

a. preclinical alzheimer's disease

b. mild cognitive decline

c. moderately severe cognitive decline

d. severe cognitive decline

C. moderately severe cognitive decline

In the moderately severe stage, deterioration is evident. Memory loss may include the

inability to remember addresses or the date. Activities such as driving may become

hazardous, and frustration by the increasing difficulty of performing ordinary tasks

may be experienced. The individual has difficulty with clothing selection. Mild cognitive decline (early-stage) Alzheimers can be diagnosed in some, but not all, individuals. Symptoms include misplacing items and misuse of words. In the stage of severe cognitive decline, personality changes may take place, and the patient needs extensive help with daily activities. This patient has symptoms, so the preclinical stage does not apply.

Consider these diagnostic findings: apolipoprotein E (apoE) malfunction, neurofibrillary tangles, neuronal degeneration in the hippocampus, and brain atrophy. Which health problem corresponds to these diagnostic findings?

a. huntington's disease

b. alzheimer's disease

c. parkinson's disease

d. vascular dementia

B. alzheimer's disease

All of the options relate to dementias; however, the pathophysiological phenomena

described apply to Alzheimers disease. Parkinsons disease is associated with

dopamine dysregulation. Huntingtons disease is genetic. Vascular dementia is the

consequence of circulatory changes.

A patient with stage 3 Alzheimer's disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time?

a. self-care deficit

b. impaired memory

c. caregiver role strain

d. adult failure to thrive

B. impaired memory

Memory impairment begins at stage 2 and progresses in stage 3. This patient is able to

perform most self-care activities. Caregiver role strain and adult failure to thrive occur

later.

A patient has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment?

a. Assist the patient to perform simple tasks by giving step-by-step directions.

b. Reduce frustration by performing activities of daily living for the patient.

c. Stimulate intellectual function by discussing new topics with the patient.

d. Read one story from the newspaper to the patient every day.

A. assist the patient to perform simple tasks by giving step-by-step directions

Two patients in a residential care facility have dementia. One shouts to the other, "Move along, you're blocking the road." The other patient turns, shakes a fist, and shouts, "You're trying to steal my car." What is the nurse's best action?

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."

C. separate and distract the patients. Take one to the day room and the other to an activities area

An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful?

a. Using the patient's glasses and hearing aids

b. Placing personally meaningful objects in view

c. Placing large clocks and calendars on the wall

d. Assuring that the room is brightly lit but very quiet at all times

A. using the patient's glasses and hearing aids

Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless.

Round-the-clock lighting promotes sensory overload and sensory perceptual alterations.

A patient diagnosed with Alzheimer's disease calls the fire department saying, "My smoke detectors are going off." Firefighters investigate and discover that the patient misinterpreted the telephone ringing. Which problem is this patient experiencing?

a. hyperorality

b. aphasia

c. apraxia

d. agnosia

D. agnosia

Agnosia is the inability to recognize familiar objects, parts of ones body, or ones own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful

movements, such as being unable to dress.

During morning care, a nurse 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?

a. sundown syndrome

b. confabulation

c. preservation

d. delirium

B. confabulation

Confabulation refers to making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The patients response was not sundown syndrome.

Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario.

A nurse counsels the family of a patient diagnosed with Alzheimer's disease who lives at home and wanders at night. Which action is most important for the nurse to recommend to enhance safety?

a. Apply a medical alert bracelet to the patient.

b. Place locks at the tops of doors.

c. Discourage daytime napping.

d. Obtain a bed with side rails.

B. place locks at the tops of doors

Placing door locks at the top of the door makes it more difficult for the patient with dementia to unlock the door because the ability to look up and reach upward is diminished. The patient will try to climb over side rails, increasing the risk for injury

and falls. Avoiding daytime naps may improve the patients sleep pattern but does not assure safety. A medical alert bracelet will be helpful if the patient leaves the home, but it does not prevent wandering or assure the patients safety.

Goals of care for an older adult patient diagnosed with delirium caused by fever and dehydration will focus on:

a. returning to premorbid levels of function.

b. identifying stressors negatively affecting self.

c. demonstrating motor responses to noxious stimuli.

d. exerting control over responses to perceptual distortions.

A. returning to premorbid levels of function

The desired overall goal is that the delirious patient will return to the level of functioning held before the development of delirium. Demonstrating motor response to noxious stimuli is an indicator appropriate for a patient whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a patient with delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for a patient with sensorium problems related to

delirium.

An older adult with moderately severe dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient's family?

a. Label the bathroom door.

b. Take the older adult to the bathroom hourly.

c. Place the older adult in disposable adult briefs.

d. Limit the intake of oral fluids to 1000 ml per day.

A. label the bathroom door

The patient with moderately severe dementia has memory loss that begins to interfere with activities. This patient may be able to use environmental cues such as labels on doors to compensate for memory loss. Regular toileting may be helpful, but a 2-hour

schedule is often more reasonable. Placing the patient in disposable briefs is more appropriate at a later stage. Severely limiting oral fluid intake would predispose the patient to a urinary tract infection.

A older patient diagnosed with severe, late-stage dementia no longer recognizes family members. The family asks how long it will be before this patient recognizes them when they visit. What is the nurse's best reply?

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."

D. "It is disappointing when someone you love no longer recognizes you."

Therapeutic communication techniques can assist the family to come to terms with the losses and irreversibility dementia imposes on both the loved one and themselves. Two incorrect responses close communication. The nurse should take the opportunity to foster communication. Consciousness does not fluctuate in patients with dementia.

A patient 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?

a. Wear large name tags.

b. Focus interaction on familiar topics.

c. Frequently repeat the reorientation strategies.

d. Place large clocks and calendars strategically

B. focus interaction on familiar topics

Reorientation may seem like arguing to a patient with cognitive deficit and increases the patients anxiety. Validating, talking with the patient about familiar, meaningful things, and reminiscing give meaning to existence both for the patient and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and placing large clocks and calendars strategically are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable because patients with dementia sometimes become more agitated with reorientation.

What is the priority need for a patient with late-stage dementia?

a. Promotion of self-care activities

b. Meaningful verbal communication

c. Preventing the patient from wandering

d. Maintenance of nutrition and hydration

D. maintenance of nutrition and hydration

In late-stage dementia, the patient often seems to have forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the patient is to live. The patient is incapable of self-care, ambulation, or verbal communication.

An older adult is prescribed digoxin (Lanoxin) and hydrochlorothiazide daily as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the patient's change in mental status?

a. drug actions and interactions

b. benzodiazepine witthdrawal

c. hypotensive episodes

d. renal failure

A. drug actions and interactions

Drug actions and interactions are common among elderly persons and predispose this population to delirium. Delirium is characterized by an abrupt onset of fluctuating

levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The patient takes lorazepam on a PRN basis, so withdrawal is unlikely. Hypotensive episodes or problems with renal function may occur

associated with the patients drug regime, but interactions are more likely the problem.

A hospitalized patient diagnosed with delirium misinterprets reality, while a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? The patients will:

a. remain safe in the environment

b. participate actively in self-care

c. communicate verbally

d. acknowledge reality

A. remain safe in the environment

An elderly patient is admitted with delirium secondary to a urinary tract infection. The family asks whether the patient will ever recover. Select the nurse's best response.

a. "The health care provider is the best person to answer your question."

b. "The confusion will probably get better as we treat the infection."

c. "Unfortunately, delirium is a progressively disabling disorder."

d. "I will be glad to contact the chaplain to talk with you."

B. "The confusion will probably get better as we treat the infection."

Usually, as the underlying cause of the delirium is treated, the symptoms of delirium clear. The distracters mislead the family.

An elderly person presents with symptoms of delirium. The family reports, "Everything was fine until yesterday." What is the most important assessment information for the nurse to gather?

a. A list of all medications the person currently takes

b. Whether the person has experienced any recent losses

c. Whether the person has ingested aged or fermented foods

d. The person's recent personality characteristics and changes

A. a list of all medications the person currently takes

Delirium is often the result of medication interactions or toxicity. The distracters relate to MAOI therapy and depression.

A nurse gives anticipatory guidance to the family of a patient diagnosed with stage 3, mild cognitive decline Alzheimer's disease. Which problem common to that stage should the nurse address?

a. violent outbursts

b. emotional disinhibition

c. communication deficits

d. inability to feed or bathe self

C. communication deficits

Families should be made aware that the patient will have difficulty concentrating and following or carrying on in-depth or lengthy conversations. The other symptoms are usually seen at later stages of the disease.