Varcarolis Ch. 23 Neurocognitive Disorders
1. 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.
c. amnestic...
Varcarolis Ch. 23 Neurocognitive Disorders
1. 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.
c. amnestic syndrome.
b. dementia.
d. Alzheimers disease. ✔️a. delirium.
Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness,
perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimers
disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment
without other cognitive problems.
2. 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
c. Tactile hallucinations
,b. Dystonia
d. Mnemonic disturbance ✔️c. Tactile hallucinations
The patient feels bugs crawling on both legs, even though no sensory stimulus is actually present. This
description meets the definition of a hallucination, a false sensory perception. Tactile hallucinations may
be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to
excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium.
3. A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration
begs, Someone get these bugs off me. What is the nurses 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 dont see any bugs, but I can tell you are frightened. I will stay with you. ✔️d. I dont see any bugs,
but I can tell you are frightened. I will stay with you.
When hallucinations are present, the nurse should acknowledge the patients feelings and state the
nurses perception of reality, but not argue. Staying with the patient increases feelings of security,
, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety.
Denying the patients perception without offering help does not support the patient emotionally. Telling
the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone
will brush the bugs away supports the perceptual distortions.
4. 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 ✔️a.
Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed
orientation, and misperception of the environment
The physical safety of the patient is of highest priority among the diagnoses given. Many opportunities
for injury exist when a patient misperceives the environment as distorted, threatening, or harmful or
when the patient exercises poor judgment or when the patients sensorium is clouded. The other
diagnoses may be concerns, but are lower priorities.
PTS: 1 DIF: Cognitive Level: Apply (Application)
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