Chapter 29: Care of Individuals with Neurocognitive Disorders Touhy: Ebersole & Hess' Toward Healthy Aging, 9th Edition MULTIPLE CHOICE 1. The nurse is caring for an older client who experienced a hip replacement surgery 10 hours
ago. Which intervention will help minimize this client’s risk of developing delirium? a. Requesting that staff offer fluids each time they interact with the client b. Medicating the client to best facilitate restorative sleep c. Encouraging the client to remain still and thus minimize pain d. Suggesting that visitors are limited to family members only ANS: A
Encouraging fluid intake will help prevent dehydration, which is a major contributor to the development of delirium. Avoid use of sleeping medications—use music, warm milk, or noncaffeinated herbal tea to alleviate discomfort and encourage sleep. Avoid excessive bed rest; institute early mobilization as appropriate. It is appropriate to have family and visitors available to the client, within reason, since doing so will help stimulate the client cognitively. DIF: Cognitive Level: Applying REF: p. 388, Box 29-10 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity 2. Which intervention best addresses the principle that is the basis for communicating with a
client experiencing postsurgical delirium? a. Reminding the client that delirium is generally acute and reversible b. Assuming that the client’s statements are an attempt to express needs c. Allowing the client sufficient time to formulate an answer to questions d. Using nonverbal communication techniques to communicate with the client ANS: B
Assuming that communication and behavior are meaningful and an attempt to tell us something or express needs is vital to effective care planning for the delirious client. The acute and reversible nature of the disorder does not have impact on the need for effective communication. The remaining options focus on the client’s communication and not the greater issue of effective intercommunication between client and staff. DIF: Cognitive Level: Analyzing REF: p. 389 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity 3. An older client admitted to the hospital after having sustained a fall at home is diagnosed with
a right hip fracture and experienced a surgical reduction of the fracture. At 2:30 AM, she awakens from sleep insisting that her daughter is in the other room and wants to see her. Attempts to reorient her to the surroundings are unsuccessful. In reviewing the client’s record, what data would be considered a primary risk factor for the delirium? a. History of dementia b. Death of the client’s husband last month c. The client’s age d. History of cardiac disease
