Question 1

When a normally oriented 87-year-old resident in a long-term care facility exhibits acute confusion, the nurse should first assess for a(n)______.

Accepted Answer

The answer of When a normally oriented 87-year-old resident in...

Question 2

A nurse caring for a patient with dementia notices that the patient stays awake most of the night.What is the nurse's most appropriate action?

Accepted Answer

A)  Give a prescribed sleeping medication. 
B)  Tell the patient that it is nighttime and that she must go to sleep. 
C)  Check the patient's record to see whether she is sleeping during the day. 
D)  Put the patient to bed and put the side rails up. 
A)  Give a prescribed sleeping medication. 
B)  Tell the patient that it is nighttime and that she must go to sleep. 
C)  Check the patient's record to see whether she is sleeping during the day. 
D)  Put the patient to bed and put the side rails up.

Question 3

A nurse is gathering information from the family of a patient who is experiencing confusion.What important question should the nurse ask the family?

Accepted Answer

A)  "Are you sure she is confused? Maybe she just didn't hear what you were saying." 
B)  "When did you first think she might be confused? Tell me exactly what happened." 
C)  "Did something bad happen to her during her childhood?" 
D)  "How can you say she is confused? She knows who she is." 
A)  "Are you sure she is confused? Maybe she just didn't hear what you were saying." 
B)  "When did you first think she might be confused? Tell me exactly what happened." 
C)  "Did something bad happen to her during her childhood?" 
D)  "How can you say she is confused? She knows who she is."

Question 4

A nurse is planning for the nutritional needs of a patient with Alzheimer disease.What is the best plan to have the dietary department provide?

Accepted Answer

A)  Pureed diet to be fed with a syringe 
B)  Foods that the patient can cut up to keep busy and not lose interest in eating 
C)  Finger foods several times a day 
D)  High-protein liquid diet 
A)  Pureed diet to be fed with a syringe 
B)  Foods that the patient can cut up to keep busy and not lose interest in eating 
C)  Finger foods several times a day 
D)  High-protein liquid diet

Question 5

A nurse has found a patient with delirium in other patients' rooms several times.What is the best action by the nurse?

Accepted Answer

A)  Firmly tell the patient that he must stay out of other patients' rooms and tell him to return to his room. 
B)  Take him back to his room and put him in bed with the side rails up. 
C)  Take him to the nurses' station and let him visit for a while. 
D)  Administer a dose of lorazepam (Ativan)as ordered. 
A)  Firmly tell the patient that he must stay out of other patients' rooms and tell him to return to his room. 
B)  Take him back to his room and put him in bed with the side rails up. 
C)  Take him to the nurses' station and let him visit for a while. 
D)  Administer a dose of lorazepam (Ativan)as ordered.

Question 6

A nurse is discussing home care of a patient with dementia with the patient's family.What should the nurse advise the family do to prevent the patient from wandering?

Accepted Answer

A)  Apply a vest restraint to keep the patient in bed or in a chair. 
B)  Put locks on any doors that it would be dangerous for the patient to open (e.g., outside doors, medicine cabinet). 
C)  Have someone remind the patient at least every 2 hours that he or she must not go outside by him or herself. 
D)  Set up a reward system for the times the patient stays where the family has requested. 
A)  Apply a vest restraint to keep the patient in bed or in a chair. 
B)  Put locks on any doors that it would be dangerous for the patient to open (e.g., outside doors, medicine cabinet). 
C)  Have someone remind the patient at least every 2 hours that he or she must not go outside by him or herself. 
D)  Set up a reward system for the times the patient stays where the family has requested.

Question 7

A patient asks a nurse, "My doctor says I get confused sometimes because I have vascular dementia.What caused me to have that?" What is the most appropriate response by the nurse?

Accepted Answer

A)  "It is usually caused from damage to brain cells because of inadequate blood supply, like a small stroke." 
B)  "It is probably just some abnormal electrical activity in your brain." 
C)  "You probably have a brain tumor." 
D)  "I'm sure he will explain it to you later." 
A)  "It is usually caused from damage to brain cells because of inadequate blood supply, like a small stroke." 
B)  "It is probably just some abnormal electrical activity in your brain." 
C)  "You probably have a brain tumor." 
D)  "I'm sure he will explain it to you later."

Question 8

What initial nursing action should be implemented when assisting a patient with dementia to dress?

Accepted Answer

A)  Hand the patient her clothes and ask her to put them on. 
B)  Hand the patient each article of clothing separately and ask her to put it on. 
C)  Assist her with each article, giving specific instructions such as, "Put your arm in this hole." 
D)  Put the patient's clothes on without assistance from the patient. 
A)  Hand the patient her clothes and ask her to put them on. 
B)  Hand the patient each article of clothing separately and ask her to put it on. 
C)  Assist her with each article, giving specific instructions such as, "Put your arm in this hole." 
D)  Put the patient's clothes on without assistance from the patient.

Question 9

An 80-year-old woman who has Alzheimer disease is restless, wanders during mealtimes, and will not sit down to eat.The nurse assisting with writing the care plan prioritizes the following interventions for the goal: The patient will eat at least 25% of each meal.______ (Prioritize the options in sequence, from the most therapeutic to the least therapeutic.Do not separate answers with a space or punctuation.Example: ABCD.)

Accepted Answer

A) Place her in a chair with a vest restraint. 
B) Assign a nursing assistant (N
A) to feed her. 
C) Give her a high-protein drink in a small cup to carry with her. 
D) Offer peanut butter crackers as she passes by. 
E) Leave her alone.She will eat when she is hungry. 
A) Place her in a chair with a vest restraint. 
B) Assign a nursing assistant (N
A) to feed her. 
C) Give her a high-protein drink in a small cup to carry with her. 
D) Offer peanut butter crackers as she passes by. 
E) Leave her alone.She will eat when she is hungry.

Exam 13: Delirium and Dementia

When a normally oriented 87-year-old resident in a long-term care facility exhibits acute confusion, the nurse should first assess for a(n)______.

A nurse caring for a patient with dementia notices that the patient stays awake most of the night.What is the nurse's most appropriate action?

A nurse is gathering information from the family of a patient who is experiencing confusion.What important question should the nurse ask the family?

A nurse is planning for the nutritional needs of a patient with Alzheimer disease.What is the best plan to have the dietary department provide?

A nurse has found a patient with delirium in other patients' rooms several times.What is the best action by the nurse?

A nurse is discussing home care of a patient with dementia with the patient's family.What should the nurse advise the family do to prevent the patient from wandering?

A patient asks a nurse, "My doctor says I get confused sometimes because I have vascular dementia.What caused me to have that?" What is the most appropriate response by the nurse?

What initial nursing action should be implemented when assisting a patient with dementia to dress?

Aspects of Medical-Surgical Nursing

Medical-Surgical Practice Settings

Medical-Surgical Patients: Individuals, Families, and Communities

Health, Illness, Stress, and Coping

Immunity, Inflammation, and Infection

Fluid, Electrolyte, and Acidbase Imbalance

The Patient With Cancer

Pain

Shock

The Older Adult Patient

Falls

Immobility

Incontinence

Nutrition

Intravenous Therapy

Surgery

The Patient With an Ostomy

Palliative and Hospice Care

Complementary and Alternative Therapies

Neurologic System Introduction

Neurologic Disorders

Cerebrovascular Accident

Spinal Cord Injury

Respiratory System Introduction

Upper Respiratory Disorders

Acute Lower Respiratory Tract Disorders

Chronic Lower Respiratory Tract Disorders

Hematologic System Introduction

Hematologic Disorders

Immunologic System Introduction

Immunologic Disorders

Cardiovascular System Introduction

Cardiac Disorders

Vascular Disorders

Hypertension

Digestive System Introduction

Upper Digestive Tract Disorders

Lower Digestive Tract Disorders

Liver, Gallbladder, and Pancreatic Disorders

Urologic System Introduction

Urologic Disorders

Musculoskeletal System Introduction

Connective Tissue Disorders

Fractures

Amputations

Endocrine System Introduction

Pituitary and Adrenal Disorders

Thyroid and Parathyroid Disorders

Diabetes and Hypoglycemia

Female Reproductive System Introduction

Female Reproductive Disorders

Male Reproductive System Introduction

Male Reproductive Disorders

Sexually Transmitted Infections

Integumentary System Introduction

Skin Disorders

Special Senses Introduction

Eye and Vision Disorders

Ear and Hearing Disorders

Psychobiological Disorders

Substance Abuse

First Aid, Emergency Care, and Disaster Management

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