Q7 MS1 Ch12 Immobility & Ch13 Delirium and Dementia

answer: C. Passive

• Passive exercises are movements of the patient’s body by another person either a therapist or a nurse.

• Isometric exercises are performed without moving the joints and are done to maintain muscle tone.

• Active exercises are performed by the person himself or herself.

• Isotonic exercises mean that the tension remains unchanged and the muscle’s length changes, such as when lifting an object at a constant speed and causing an isotonic contraction.

A patient who sustained a head injury has not regained consciousness. The nurse moves the patient’s joints through their normal movements twice a day. This exercise intervention is called?

A. Isometric

B. Active

C. Passive

D. Isotonic

Answer. 2) REPOSITION THE PATIENT AT LEAST EVERY 2 HOURS.

• skin integrity is best maintained by the repositioning the patient at least every 2 hours.

• keeping joints in functional positions is directef toward making sure joints are not abnormally flexed or extended.

• the purpose of ROM exercises is to put each joint that is at risk for loss of water does not prevent skin breakdown.

• better to offer the patient a glass of water with each position change.

The nursing care plan for an immobilized patient includes the following interventions. Which one is specifically intended to maintain skin integrity?

1. keep joints in functional positions

2. reposition the patient at least every 2 hours

3. perform range of motion twice daily

4. give at least eight 8-ounce glasses of fluids each day.

answer: 1) DOCUMENT ERYTHEMA AND INSTRUCT NURSING ASSISTANTS TO KEEP THE PATIENT OFF HIS BACK.

• The first action to take when recognizing an erythematous area on a patient is to document the erythema and instruct assistants to keep the patient off his back.

• The Norton scale could also be used to identify if the patient is at risk for developing a pressure injury.

• Reddened areas should never be massaged because that could cause damage to fragile capillaries.

• Inflatable rings also should not be used because they can cause a concentrated area of pressure and place the patient at a higher risk for developing pressure injury.

• Heat should not be used because it can increase the patient’s temperature and the metabolic demands of the tissue and put additional stress on the affected area.

During a bed bath, you observe a reddened area over the sacrum. You should:

1. Document erythema and instruct nursing assistants to keep the patient off his back.

2. Gently massage the reddened area with skin lotion to provide protective moisture

3. Place a round inflatable cushion under the patient’s buttocks to relieve pressure on the sacrum

4. Position the patient on one side and use a heat lamp to stimulate circulation to the area

ANS: 1) VALSALVA MANEUVER

• Constipated patients may strain to defecate, leading to an increase in intraabdominal pressure.

• The most likely cause is related to the Valsalva maneuver or vasovagal reflex. Especially in older adults, this can lead to cardiovascular alterations, including lightheadedness and fainting.

• The vasovagal reflex is not related to internal hemorrhage, dehydration, or wound dehiscence (suture line separation.)

A postoperative patient reports that she was straining to have a bowel movement when she became light-headed. You should suspect which of the following?

1. Valsalva maneuver

2. Internal hemorrhage

3. Dehydration

4. Wound dehiscence

Answer: 2) POOLING OF URINE IN THE URINARY SYSTEM

• Urine flows downward from the kidneys by gravity, so when the patient is in a reclining or supine position, the urine flow gets sluggish and urine pools, putting the patient at risk for a urinary tract infection (UTI).

• Immobility itself does not affect the amount of urine produced by the kidneys, but the peristaltic action of the ureters is not strong enough to maintain a constant flow of urine.

• There is not increased blood flow to the kidneys.

• Without the downward pressure on a full bladder against the sphincter muscles, awareness of the need to void is less.

What is the effect of immobility on the urinary tract?

1. Decreased urine production by the kidneys

2. Pooling of urine in the urinary system

3. Increased blood flow to kidneys

4. Increased bladder sensitivity to fullness

Answer: 1) CONTRACTURES

• Shortening of muscles and tendons creates a contracture that is defined as “a lack of full active or passive range of motion because of joint, muscle, or soft tissue limitations”.

• A contracture can severely and permanently limit joint movement. Range-of-motion exercises should be initiated early in immobile patients to prevent contractures.

What is the result of little or no motion of the joints?

1. Contractures

2. Tendonitis

3. Bursitis

4. Skin breakdown

Answer: 2) SACRUM

• The most frequent sites of skin breakdown are the sacrum (35%), ischial tuberosities (16%), heels (11%), trochanters (7%), ankles (3%), and scapulae (2%).

What is the most frequent site of skin breakdown?

1. Ischial tuberosities

2. Sacrum

3. Heels

4. Trochanter

Answer: 3) FREQUENT POSITION CHANGES

The best preventive measure for pressure injuries is:

1. a high-protein diet.

2. deep-breathing.

3. frequent position changes.

4. moderate exercise.

Answer: CLEAN WITH WATER OR NORMAL SALINE

• In general, stages I and II pressure injuries should be cleaned with water or normal saline.

• Avoid pastes, creams, ointments, and powder because they may interfere with healing.

• In addition, alcohol, antiseptics, and disinfectants are not used because their effectiveness has not been proven; they may actually cause harm.

• Stages I and II ulcers are not usually infected, therefore topical and oral antibiotics are not appropriate.

What is the recommended treatment for stage l and stage Il pressure injuries?

1. Use antibiotic creams and ointments.

2. Apply heat to the area around the pressure injury.

3. Clean with alcohol and antiseptics.

4. Clean with water or normal saline.

answer: 4) EXCHANGE OF OXYGEN AND CARBON DIOXIDE IN THE LUNGS

• When a person remains immobile or does not take deep breaths, thick secretions can accumulate and pool in the lower respiratory structures.

• These secretions interfere with the normal exchange of gases, can cause areas of the lung to collapse (atelectasis), and can provide an environment for growth of pathogens.

A 60-year-old patient with pneumonia has thick secretions pooled in the lower respiratory structures. These secretions interfere with the:

1. exchange of white blood cells and red blood cells in the capillaries.

2. circulation of blood to the extremities

3. detoxification process in the liver.

4. exchange of oxygen and carbon dioxide in the lungs.

answer: 4) IDENTIFY PATIENTS RISK FOR DEVELOPING PRESSURE INJURY

• The first step in the prevention of pressure ulcers is to identify patients at risk for developing pressure ulcers (4).

The nurse is taking care of three patients who are newly admitted to an assisted-living facility. As the nurse collects data to assist in planning their care, the nurse focuses on prevention of pressure injuries. What is the first step in the prevention of pressure injuries?

1. Reposition the patient in bed at least every 2 hours.

2. Keep bed linens dry, smooth, and free of wrinkles.

3. Use a special mattress or bed designed to reduce pressure.
   Identify patients at risk for developing pressure injuries.

4. Identify patient’s risk for developing pressure ulcers

answer: 1) increase anxiety

• The patient with delirium may pull on tubes, try to get out of bed unassisted, or attempt to leave the setting.

• Protecting the patient from harm without imposing excessive restrictions can be challenging.

• Avoid physical restraints, which tend to increase anxiety and agitation in confused patients and often result in injuries.

• Instead, ask a family member to remain with the patient or assign a staff member to do so.

The use of physical restraints should be avoided with patients with delirium because restraints tend to:

1. increase anxiety.

2. disturb thought processes.

3. increase impaired thinking.

4. disturb sleep patterns.

answer: 2) AVOID CONFRONTATIONS

• When patients resist activities such as bathing or dressing, avoid confrontations, which only provoke agitation and possible violence.

• Instead, come back at another time.

When a patient with dementia resists activities such as bathing or dressing, the nurse should:

1. orient the patient to reality.

2. avoid confrontations.

3. state clearly what needs to be done.

4. offer a variety of choices to encourage decision-making.

answer: 3) REALITY ORIENTATION

• Whereas frequent reality orientation is helpful for the patient with delirium, such orientation is not effective for the patient with dementia.

• Clocks, calendars, constant mention of the date and time, and other such orientation reminders used to be a staple of care for patients with dementia.

• However, reality orientation may agitate people with dementia.

1. Which approach may agitate patients with dementia?

1. A nonconfrontational manner

2. Use of calm, gentle mannerisms

3. Reality orientation

4. Use of simple, direct communication

answer: 4) DIVERT HER ATTENTION AND GENTLY GUIDE HER TO A NEW ACTIVITY

• If patients with dementia start to become very restless or agitated, an effective orientation is to divert their attention and gently guide them to a new activity (4).

• Usually, within a relatively short time, they will forget what was bothering them in the first place and focus on the new activity.

A female patient with dementia starts to become very restless and agitated. Which is an effective nursing intervention for this patient?

1. Discuss the cause of her discomfort with her.

2. Speak calmly and reassure her constantly.

3. Orient her to time and place.

4. Divert her attention and gently guide her to a new activity.

answer: 4) ARRANGE ANOTHER WAY TO GIVE PERSONAL CARE.

• If a patient with dementia tells the nurse that he is afraid of bathtubs, the nurse should arrange another way to give personal care

  (4).

• (1), reassurance, is not a

  therapeutic communication

  technique.

• (2), explaining the need for a bath, is not effective with patients with dementia.

• (3) is incorrect because patients with dementia should be offered a limited number of choices, not a wide variety of choices.

A patient with dementia tells the nurse that he is afraid of bathtubs. The nurse's best response is to:

1. reassure the patient that there is nothing to be afraid of.

2. explain the reason for taking a bath in the bathtub.

3. offer a variety of choices to the patient about taking a bath.

4. arrange another way to give personal care.

answer: 3) A BACK RUB, A GLASS OF WARM MILK, AND SOOTHING CONVERSIONS

• Nursing measures such as giving a backrub, providing a glass of warm milk, and having a soothing conversation may help the patient relax and fall asleep.

• These can be effective with a patient experiencing delirium.

• Encourage the patient to void before

  bedtime.

• Schedule medications or treatments at times that do not interrupt nighttime sleep.

• The presence of a family member may help calm an agitated and confused patient.

A patient with delirium is having trouble falling asleep. Which is the most appropriate nursing intervention to help this patient fall asleep?

1. A walk followed by a shower

2. Pain medication and watching a movie

3. A backrub, a glass of warm milk, and soothing conversation

4. A sedative and reality orientation

answer: 1) DELIRIUM IS TYPICALLY REVERSIBLE; DEMENTIA IS USUALLY IRREVERSIBLE

• The primary difference between delirium and dementia is that delirium is typically reversible while dementia is usually irreversible.

• Agitation is not constant with delirium, and delirious people may be hyperactive, hypoactive, or alternate between the two.

• With dementia, agitation is constant with a gradual slow progression to combativeness, delusions, hallucinations, and wandering in later stages.

• Delirium develops over a short period of time, while dementia has an insidious onset with gradual steady progression in cognitive and behavioral symptoms.

• Delirium can last for quite a while and depends upon managing the symptoms and treating or removing the cause while maintaining safety and comfort to reduce anxiety.

• Dementia is not reversible and is defined as a progressive and significant cognitive decline from a previous level of performance.

1. What is the primary difference between delirium and dementia?

1. Delirium is typically reversible; dementia is usually irreversible

2. Agitation is constant with delirium but intermittent with

3. The onset of delirium is gradual; the onset of dementia is typically rapid.

4. Delirium usually lasts only a few minutes; dementia lasts weeks to months.

answer: 3) CALMLY TELL HER WHERE SHE IS AND THAT HER DAUGHTER IS NOT THERE.

• The best intervention is to be honest and tell the patient where she is and that her daughter is not there.

• Frequent orientation to the surroundings and the situation is important for patients with delirium.

• Sedatives and antipsychotic drugs should be used with great caution with older adult patients because they can increase the risk of death.

• Calling her daughter in the middle of the night and asking her to come to see her mother and scolding the patient and telling her to be quiet because she is disturbing other patients are not reasonable or appropriate interventions.

A delirious patient repeatedly cries out for her daughter in the middle of the night. What is the best intervention?

1. Check to see whether she has an order for a sedative.

2. Call the daughter and ask her to come see the patient.

3. Calmly tell her where she is and that her daughter is not there.

4. Tell her she needs to be quiet because she is disturbing other patients.

answer: 1) CONSULT WITH THE DIETITIAN ABOUT PROVIDING FINGER FOODS.

• When a patient with Alzheimer's disease (AD) wanders away from the table during meals, the nurse should consult a dietitian to see if finger foods can be provided for the patient.

• Avoid physical restraints as they can cause anxiety and agitation in confused patients and often can result in patient injuries.

• Arguing and ordering the patient to sit down and finish his meal does not convey respect and dignity and is not an appropriate action.

• Asking another patient for help can put the other patient at risk for injury.

A patient with AD wanders away from the table during meals, leaving most of his food uneaten. What should you do?

1. Consult with the dietitian about providing finger foods.

2. Restrain the patient in his seat during meals.

3. Tell him he must sit down and finish his meal.

4. Ask another patient to try to keep him at the table.

answer: 2) “PUT YOUR ARM IN THE SLEEVE OF YOUR SHIRT.”

• When addressing a patient with dementia, it is best to be direct and keep instructions simple.

• Telling the patient that he needs to be dressed in 30 minutes to go to church is too detailed and telling him to "put his shirt" on needs to be more direct.

• Also, asking him what he wants to wear can be too confusing and cause anxiety.

When addressing a person who has dementia, which message is most appropriate?

1. "You need to be dressed for church in 30 minutes."

2. "Put your arm in the sleeve of your shirt."

3. "Put your shirt on."

4. "What would you like to wear today?"

answer: 3) ALZHEIMER DISEASE

• Donepezil (Aricept) is used for Alzheimer disease.

• Patients with vascular dementia are treated with anti-platelet medications.

• Patients with Huntington disease are treated with antipsychotics, anticonvulsants, antidepressants, and benzodiazepenes.

• Selective serotonin reuptake inhibitors are used to treat depression associated with frontotemporal dementia

The nurse is reviewing the medication administration record and notes that the patient has an order to receive donepezil (Aricept) 5 mg PO every day at bedtime. Which disorder does the nurse knows that this patient has been diagnosed with?

1. Vascular dementia

2. Huntington disease

3. Alzheimer disease

4. Frontotemporal dementia

answer: 2) MAKE THE PATIENT’s SURROUNDINGS AS SAFE AS POSSIBLE.

• If the patient begins to thrash and strike out, the nurse should first lower the bed to the lowest setting, remove all objects that the patient could pull onto himself, and ensure that the patient does not hurt himself or others.

• After the surroundings are safe, the nurse should attempt to reorient the patient by identifying him- or herself to the patient and telling the patient that he is ill and in the hospital and that there are no monsters.

• If the patient does not calm down, the nurse may need to call for help.

• It is inappropriate to step out of the room until the patient has calmed down and is no longer in immediate danger of harming himself.

The nurse is attempting to turn in bed a patient who is experiencing delirium. The patient begins to strike out, thrash, and scream that a monster is attacking him. What should be the nurse's priority intervention?

1. Call for help.

2. Make the patient's surroundings as safe as possible.

3. Step out of the room; the patient clearly does not want to be turned.

4. Tell the patient that he is in a safe place and that the monster is not real.

Answer: 3) “REGARDLESS OF TREATMENT, MY MOTHER’s MENTAL STATUS WILL NOT IMPROVE.”

• If the cause of the patient's delirium is determined and resolved, the patient will most likely experience in a resolution of the delinum as well.

• Symptoms that worsen at night, depression, anxiety, and difficulties processing one's environment are all characteristic of delirium.

The nurse is educating the daughter of an older adult patient who was diagnosed with delirium. Which statement made by the daughter indicates a need for further teaching?

1. “My mother is likely to have symptoms that are worse at night”

2. “It is possible my mother will also experience depression and anxiety “

3. “Regardless of treatment, my mother’s mental status will not improve.”

4. “My mother may experience difficulties understanding her environment.”

Answer: 3) TURNING OFF ALL THE LIGHTS IN THE PATIENT’s ROOM SO THE PATIENT CAN SLEEP

• The nurse should intervene if the UAP turns off all the lights in the patient's room.

• The UAP should leave on a night-light or some other soft, diffuse light to decrease the shadows in the room.

• The patient will likely be afraid of the dark.

• If the patient requires glasses or hearing aids, they should be on whenever the patient is awake.

• Additionally, clocks, pictures, and calendars should be placed near the patient to help orient the patient to person and time.

The LPN/LVN is supervising the care of a patient with confusion. Which action by the unlicensed assistive personnel (UAP) would prompt the LPN/LVN to intervene?

1. Putting on the patient's glasses so the patient can see

2. Putting in the patient's hearing aids so the patient can hear

3. Turning off all the lights in the patient's room so the patient can sleep

4. Placing the patient's clock in a prominent position so the patient knows what time it is

answer: 3) INTERNAL FIXATION

• Internal fixation includes the use of rods, pins, nails, screws, or metal plates to align bone fragments and keep them in place for

  healing.

• External fixation is similar to internal fixation, but the pins are inserted directly into the bone, above and below the fracture.

• Closed reduction or manipulation is the nonsurgical realignment of the bones that returns them to their previous anatomic position.

• Mechanical reduction Is not a procedure used.

The use of rods, pins, nails, screws, or metal plates to align bone fragments is called:

1. external fixation.

2. closed reduction.

3. internal fixation.

4. mechanical reduction.

answer: 4) “AS I UNDERSTAND IT, THIS MEDICATION WILL SLOW THE PROGRESS OF THE NEURODEGENERATION CAUSED BY ALZHEIMER DISEASE”

• Donezepil (Aricept) are acetylcholinesterase inhibitors that allow acetylcholine to accumulate at cholinergic synapses, causing prolonged and exaggerated cholinergic effects.

• Donezepil (Aricept) does not prevent or slow the nuerodegeneration caused by AD.

The nurse is educating the family of an elderly patient on the mechanism of action for donepezil (Aricept). Which statement by the family indicates that further teaching is needed?

1. "As I understand it, this drug will improve the cognitive skills of my dad."

2. "So you are saying that this drug is used in patients with mild to moderate dementia caused by Alzheimer disease."

3. "Are you saying that the enzyme that normally breaks down acetylcholine is inhibited by this medication?"

4. "As I understand it, this medication will slow the progress of the neurodegeneration caused by Alzheimer disease."

answers:

• 1) DECREASED FLEXIBILITY

• 2) DECREASED STRENGTH

• 3) CHANGES IN POSTURE

• 4) CHANGES IN GAIT

• 7) LIKELIHOOD OF HAVING ONE OR MORE CHRONIC ILLNESSES

  • Chronic medical conditions such as arthritis, stroke, Parkinson disease, cardiovascular disease, anemia, pulmonary disease, and foot deformities can lead to decreased mobility.

• Pain may also be a factor that leads to immobility in older adults.

• Drugs that cause drowsiness, hypotension, or dizziness can affect mobility as well.

Which common aging changes place the older adult at risk for immobility and its consequences? Select all that apply.

1. Decreased flexibility

2. Decreased strength

3. Changes in posture

4. Changes in gait

5. Decreased kidney function

6. Decreased neurons in brain

7. Likelihood of having one or more chronic illnesses

answers:

• 1) ARTHRITIS

• 2) CARDIOVASCULAR DISEASE

• 4) STROKE

• 5) ANEMIA

• 7) PARKINSON DISEASE

• 8) FOOT DISORDERS

• Chronic medical conditions such as arthritis, stroke, Parkinson disease, cardiovascular disease, anemia, pulmonary disease(COPD), osteoporosis, depression and foot deformities can lead to decreased mobility.

Which common medical illnesses place the older person at risk for immobility and its consequences? Select all that apply.

1. Arthritis

2. Cardiovascular disease

3. Diabetes mellitus

4. Stroke

5. Anemia

6. Thyroid disorders

7. Parkinson disease

8. Foot disorders