Chapter 59: Dementia and Delirium Harding: Lewis's Medical-Surgical Nursing, 11th Edition Exam Questions and Answers
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Course
Lewis Medical Surgical Nursing
Institution
Lewis Medical Surgical Nursing
Chapter 59: Dementia and Delirium Harding: Lewis's
Medical-Surgical Nursing, 11th Edition Exam
Questions and Answers
A patient hospitalized with pneumonia is disoriented and confused 3 days after admission. Which
information indicates that the patient is experiencing delirium rather than dement...
The patient 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 patient with
severe dementia, who would have difficulty with swallowing, self-care, and immobility.
What action should the nurse incorporate when administering a mental status examination to a patient
with delirium? - Ans:✔✔-Choose a place without distracting stimuli.
Rational:
Because overstimulation by environmental factors can distract the patient from the task of answering
the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination
because action to correct the delirium should occur as soon as possible. Reorienting the patient is not
appropriate during the examination. Antianxiety medications may increase the patient's delirium.
The nurse is concerned about a postoperative patient's risk for injury during an episode of delirium.
What is the nurse's most appropriate action? - Ans:✔✔-Assign unlicensed assistive personnel (UAP) to
stay with and reorient the patient.
Rational:
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 should be
avoided, when possible, because they can increase the patient's agitation and disorientation.
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