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NUR 283 COMPREHENSIVE EXAM 1 STUDY GUIDE 2024/CORRECT AND VERIFIED RESPONSES WITH EXPLANATIONS - GALEN COLLEGE OF NURSING graded a+
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NUR 283 COMPREHENSIVE 2024/COR
NUR 283 COMPREHENSIVE EXAM 1 STUDY GUIDE
2024/CORRECT AND VERIFIED RESPONSES WITH
EXPLANATIONS - GALEN COLLEGE OF NURSING graded a+
1. An older adult patient takes multiple medications daily. Over 2 days,
the patient developed confusion, slurred speech, an unsteady gait, and
fluctuating le...
NUR 283 COMPREHENSIVE EXAM 1 STUDY GUIDE
2024/CORRECT AND VERIFIED RESPONSES WITH
EXPLANATIONS - GALEN COLLEGE OF NURSING graded a+
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.
b. dementia
c. amnestic syndrome.
d. Alzheimer's disease. - ANS-ANS: A
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
Alzheimer's 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
b. dystonia
c. Tactile hallucinations
d. Mnemonic disturbance - ANS-ANS: C
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 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." - ANS-ANS: D
When hallucinations are present, the nurse should acknowledge the
patient's feelings and state the nurse's 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 patient's 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 - ANS-ANS: A
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 patient's
, sensorium is clouded. The other diagnoses may be concerns, but are
lower priorities.
5. What is the priority intervention for a patient diagnosed with
delirium who has fluctuating levels of consciousness, disturbed
orientation, and perceptual alterations?
a. Distraction using sensory stimulation
b. Careful observation and supervision
c. Avoidance of physical contact
d. Activation of the bed alarm - ANS-ANS: B
Careful observation and supervision are of ultimate importance
because an appropriate outcome would be that the patient will remain
safe and free from injury. Physical contact during care cannot be
avoided. Activating a bed alarm is only one aspect of providing for the
patient's safety.
6. A patient diagnosed with delirium is experiencing perceptual
alterations. Which environmental adjustment should the nurse make for
this patient?
a. Provide a well-lit room without glare or shadows. Limit noise and
stimulation.
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