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NUR 304 - Chapter 23 Questions and answers 2025.
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NUR 304 - Chapter 23 Questions and answers 2025.
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NUR 304 - Chapter 23Questions and answers 2025
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 - answer D. delirium
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 - answer C. tactile hallucinations
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." - answer 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 - answer 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?
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