Delirium is often the result of medication interactions or toxicity. The distracters relate to MAOI (monoamine oxidase inhibitor) therapy and depression. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 23-3, 4, 45 (Table 23-4) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 29. A nurse gives anticipatory guidance to the family of a patient diagnosed with mild early stage
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Alzheimer’s disease. Which problem common to that stage should the nurse address? a. Violent outbursts b. Emotional disinhibition c. Communication deficits d. Inability to feed or bathe self ANS: C
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Families should be made aware that the patient will have difficulty concentrating and following or carrying on in-depth or lengthy conversations. The other symptoms and problems are usually seen at later stages of the disease.
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PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 23-43 (Table 23-3) | Pages 23-22, 47 (Table 23-5) | Page 23-30 (Case Study and Nursing Care Plan 23-1) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
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MULTIPLE RESPONSE
1. A patient diagnosed with moderate stage Alzheimer’s disease has a self-care deficit of
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dressing and grooming. Designate appropriate interventions to include in the patient’s plan of care. (Select all that apply.) a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patient’s name and name of the item. c. Administer antianxiety medication before bathing and dressing. d. Provide necessary items and direct the patient to proceed independently. e. If the patient resists dressing, use distraction and try again after a short interval. ANS: A, B, E
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Providing clothing with elastic and hook-and-loop closures facilitates patient independence. Labeling clothing with the patient’s name and the name of the item maintains patient identity and dignity (provides information if the patient has agnosia). When a patient resists, it is appropriate to use distraction and try again after a short interval because patient’s moods are often labile. The patient may be willing to cooperate given a later opportunity. Providing the necessary items for grooming and directing the patient to proceed independently are inappropriate. Be prepared to coach by giving step-by-step directions for each task as it occurs. Administering anxiolytic medication before bathing and dressing is inappropriate. This measure would result in unnecessary overmedication.
PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 23-22, 47 (Table 23-5) | Pages 23-24, 25, 53 (Table 23-8) | Page 23-30 (Case Study and Nursing Care Plan 23-1) TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
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