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Chapter 62: Nursing Management: Delirium, Alzheimer’s Disease, and OtherDementias
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is caring for a client who is hospitalized with pneumonia and is disoriented and
confused 2 days after admission. Which of the following information obtained by the
nurse about the client indicates that the client is experiencing delirium rather than
dementia?
a. The client was oriented and alert when admitted.
b. The client’s speech is fragmented and incoherent.
c. The client is disoriented to place and time but oriented to person.
d. The client has a history of increasing confusion over several years.
ANS: A
The onset of delirium occurs acutely. The degree of disorientation does not differentiate
between delirium and dementia. Increasing confusion for several years is consistent with
dementia. Fragmented and incoherent speech may occur with either delirium or dementia.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
2. The nurse is developing a plan of care for a hospitalized client with moderate dementia.
Which of the following interventions should the nurse include?
a. Provide complete personal hygiene care for the client.
b. Remind the client frequently about being in the hospital.
c. Reposition the client frequently to avoid skin breakdown.
d. Place suction at the bedside to decrease the risk for aspiration.
ANS: B
The client with moderate dementia will have problems with short- and long-term memory
and will need reminding about the hospitalization. The other interventions would be used
for a client with severe dementia, who would have difficulty with swallowing, self-care,
and immobility.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
3. The nurse is caring for a client with dementia with lewy bodies (DLB). Which of the
following complications is the client most at risk for developing related to DLB?
a. Stroke
b. Pneumonia
c. Myocardial infarction
d. Urinary tract infection
ANS: B
Pneumonia is a common complication in clients with DLB. They are not at an increased
risk of stroke, MI, or urinary tract infection related to the DLB.
, DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Psychosocial Integrity
4. Which of the following actions is most appropriate for the nurse to implement to protect a
client from injury during an episode of delirium?
a. Secure the client in bed using a soft chest restraint.
b. Ask the health care provider about ordering an antipsychotic drug.
c. Instruct family members to remain with the client and prevent injury.
d. Assign a nursing assistant to stay with the client and offer frequent reorientation.
ANS: D
The priority goal is to protect the client from harm, and a staff member will be most
experienced in providing safe care. Visits by family members are helpful in reorienting the
client, but families should not be responsible for protecting clients from injury.
Antipsychotic medications may be ordered, but only if other measures are not effective
because these medications have multiple adverse effects. Restraints are sometimes used
but tend to increase agitation and disorientation.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
5. Which of the following actions should the nurse in the outpatient clinic include in the plan
of care for a client with mild cognitive impairment (MCI)?
a. Suggest a move into an assisted-living facility.
b. Schedule the client for annual appointments.
c. Ask family members to supervise the client’s daily activities.
d. Discuss the preventive use of acetylcholinesterase medications.
ANS: B
Ongoing monitoring is recommended for clients with MCI. If mild cognitive impairment
(MCI) is diagnosed, annual monitoring of symptoms and functioning is recommended.
MCI does not interfere with activities of daily living, acetylcholinesterase drugs are not
used for MCI, and an assisted-living facility is not indicated for MCI.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Psychosocial Integrity
6. The nurse is administering a mental status examination to a client. Which of the following
client responses should lead the nurse to suspect possible depression?
a. “I don’t know.”
b. “Is that the right answer?”
c. “Wait, let me think about that.”
d. “Who are those people over there?”
ANS: A
Answers such as “I don’t know” are more typical of depression. The response “Who are
those people over there?” is more typical of the distraction seen in a client with delirium.
The remaining two answers are more typical of a client with dementia.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Psychosocial Integrity
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