Alzheimer's(NCLEX ) Study Guide Exam And All Actual Answers.
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Course
Alzheimer\'s Disease
Institution
Alzheimer\'s Disease
A 72-year-old patient hospitalized with pneumonia is disoriented and confused 2 days after admission. Which assessment information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia?
a.
The patient is disoriented to place and time but ...
Alzheimer's(NCLEX ) Study Guide Exam And All Actual Answers.
A 72-year-old patient hospitalized with pneumonia is disoriented and confused 2 days after admission. Which assessment information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia?
a.
The patient is disoriented to place and time but oriented to person.
b.
The patient has a history of increasing confusion over several years.
c.
The patient's speech is fragmented and incoherent.
d.
The patient was oriented and alert when admitted. - Answer Correct Answer: D
Rationale: 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.
Cognitive Level: Application Text Reference: p. 1562
Nursing Process: Assessment NCLEX: Physiological Integrity
When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse include?
a.
Reminding the patient frequently about being in the hospital
b.
Placing suction at the bedside to decrease the risk for aspiration
c.
Providing complete personal hygiene care for the patient
d. Repositioning the patient frequently to avoid skin breakdown - Answer Correct Answer: A
Rationale: 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.
Cognitive Level: Application Text Reference: p. 1563
Nursing Process: Planning NCLEX: Physiological Integrity
3. When administering a mental status examination to a patient with delirium, the nurse should
a.
give the examination when the patient is well-rested.
b.
reorient the patient as needed during the examination.
c.
choose a place without distracting environmental stimuli.
d.
medicate the patient first to reduce anxiety. - Answer Correct Answer: C
Rationale: 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.
Cognitive Level: Application Text Reference: pp. 1562, 1576-1577
Nursing Process: Implementation NCLEX: Physiological Integrity
To protect a patient from injury during an episode of delirium, the most appropriate action by the nurse is to
a.
have a close family member remain with the patient and provide reassurance.
b.
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