Question 1

In assessing a patient for the possibility of confusion,the nurse should keep in mind that the two major types of confusion are:

Accepted Answer

A)  Acute and chronic senility 
B)  Temporary and permanent confusion 
C)  Delirium and dementia 
D)  Senility and senile dementia

Question 2

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

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."

Question 3

Although unclear,it is believed that Alzheimer disease is caused by:

Accepted Answer

A)  Amyloid deposits in the brain 
B)  Excess of acetylcholine 
C)  Neurofibrillary tangles 
D)  Infiltration of Lewy bodies 
E)  Series of small strokes

Question 4

The nurse is taking a patient who has Alzheimer disease to the bathing room for a tub bath.The patient states,"Please don't make me take a bath today.I am so afraid that I will be washed down the drain." The nurse's best response would be:

Accepted Answer

A)  "Don't be silly, there's no way you would fit in the drain." 
B)  "I am your nurse, and I will stay with you, so you shouldn't be afraid of your bath." 
C)  "Let's go back to your room, and I will bathe you there." 
D)  "Today is your day for a bath."

Question 5

The nurse is preparing a room for a patient being transferred from the emergency department with a diagnosis of delirium.The nurse should ensure that the room is:

Accepted Answer

A)  Brightly lit 
B)  Shared by another patient 
C)  Visible from the nurses' station 
D)  Dark and quiet

Question 6

When admitting a patient who has recently become confused,the nurse asks the family for a list of all the medications that the patient is currently taking.The nurse is aware that the medication that could be causing confusion is:

Accepted Answer

A)  Amoxicillin 
B)  Acetaminophen 
C)  Furosemide 
D)  Digoxin

Question 7

The 80-year-old woman who has Alzheimer disease is restless,wanders during mealtime,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)
A) Place her in a chair with a vest restraint.
B) Assign an nursing assistant (NA) 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.

Accepted Answer

The answer of The 80-year-old woman who has Alzheimer disease...

Question 8

The patient asks the nurse what causes dementia.The nurse's response would be based on the understanding that the two most prevalent types of dementia are:

Accepted Answer

A)  Pick disease and Huntington disease. 
B)  Alzheimer disease and vascular dementia. 
C)  Creutzfeldt-Jakob disease and Pick disease. 
D)  Vascular dementia and Huntington disease.

Question 9

A patient has been admitted with a diagnosis of confusion.The physician's admission note states that he wants to assess for delirium versus dementia.The nurse knows that the main differences are:

Accepted Answer

A)  Delirium usually lasts several years, whereas dementia lasts only a few days. 
B)  Delirium usually has sudden onset and is reversible, whereas dementia is chronic and irreversible. 
C)  Dementia is usually caused by medications, whereas delirium is not. 
D)  Dementia is easily treated with reality orientation, whereas delirium is not.

Question 10

The nurse is discussing home care of the patient with dementia with the patient's family.The nurse should advise the family to prevent the patient from wandering by:

Accepted Answer

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

Exam 22: Confusion