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 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

2. Which intervention best addresses the principle that is the basis for communicating with a client experiencing postsurgical delirium?

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 a. History of dementia b. Death of the client’s husband last month c. The client’s age d. History of cardiac disease

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?

ANS: A

Older people who have undergone surgery and those with dementia are particularly vulnerable to delirium. While the other options may be factors, they are not as influential as the correct option.

DIF: Cognitive Level: Applying REF: p. 383

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Psychosocial Integrity a. “Let’s think about what you may have done to anger your father?” b. “Let’s try to figure out what your father was trying to say with his behavior.” c. “Scratching is usually a sign of untreated pain. Do you think your father is in pain?” d. “Maybe you should consider having a home health care provider take over responsibility for your father’s physical care.”

4. An older client diagnosed with dementia resides with his daughter. When the homecare nurse visits, the daughter tearfully tells the nurse that her father scratched her hand and cursed at her when she was attempting to feed him. She states, “I don’t know why he hates me and wants to hurt me. I try so hard to take good care of him. I love him.” How will the nurse respond to the client’s daughter?

ANS: B

Dementia often interferes with the person’s communication and the ability to understand and express thoughts and feelings. The focus needs to be on what the person is attempting to communicate through behavior. Behavioral manifestations are not necessarily signs of anger in persons with dementia. Although behavioral manifestations frequently are seen in persons with untreated pain, this is not always true. The issue here is not necessarily the individual who is providing the care but perhaps the care activity itself. It is appropriate for the daughter to provide care for her father.

DIF: Cognitive Level: Applying REF: p. 395

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Psychosocial Integrity a. Normal attention span b. Fluctuation in symptoms c. Normal sleep cycle d. Increased appetite

5. A nurse is caring for a patient with a diagnosis of delirium. Which of the following is an expected assessment finding for this patient?

ANS: B

A hallmark of delirium is fluctuation in symptoms. Patients with delirium typically have decreased attention spans and an altered sleep-wake cycle. Classic symptoms of delirium do not involve changes in appetite; however, patients often have a decreased appetite.

DIF: Cognitive Level: Understanding REF: p. 385

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Psychosocial Integrity

Multiple Response

1. Which intervention to manage wandering in clients in a long-term care facility should be implemented? (Select all that apply.)

a. Camouflaging doorways b. Close observation to identify the person’s individual patterns c. Engaging the person in social interactions d. Using physical restraints to prevent wandering to maintain safety e. Providing enclosed pathways for walking

ANS: A, B, C, E

Restraints are not an effective intervention for wandering. Although they might physically prevent the person from wandering, restraints have many potential negative consequences and patient harm associated with their use. Environmental modifications such as camouflaging doorways and providing enclosed pathways, close observation to identify the person’s individual patterns, and engaging the person in social interactions are all interventions that are effective strategies to manage wandering.

DIF: Cognitive Level: Applying REF: p. 388

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Psychosocial Integrity a. The delirious client learns to make up answers to hide his or her confusion. b. Delirium requires increased monitoring at night. c. The client diagnosed with dementia generally looks frightened. d. Dementia results in a steady decline in cognitive abilities. e. Delirium is characterized by fluctuations in alertness.

2. Which information will the nurse manager include when discussing the major differentiation between delirium and dementia with novice nurses? (Select all that apply.)

ANS: B, D, E

The correct options accurately describe the conditions. It is the client experiencing dementia who will over the course of the illness learn to confabulate to cover up his or her memory losses, and the delirious client is more likely to show fear through facial expressions.

DIF: Cognitive Level: Applying REF: p. 382, Table 29-1

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Psychosocial Integrity a. Age of 92 b. Residing in an assisted living facility c. History of dementia d. Female gender e. Recent cataract surgery

3. A nurse is caring for a 92-year-old female patient who was admitted to the hospital 1 day after she had outpatient cataract surgery. The patient who lives in an assisted living facility became very confused and agitated and was found wandering in the lobby of the building in her nightgown. She refused to return to her room and stated that there were “bad men” in her room. The patient has a history of dementia, diabetes, heart failure, and is on seven different medications. She was widowed 1 year ago. The nurse suspects that she has delirium. What are the patient’s risk factors for delirium? (Select all that apply.)

ANS: A, C, E

This patient’s risk factors for delirium include her older age, history of dementia, and recent surgery. There is no evidence that living in an assisted living facility or being female increase risk of delirium.

DIF: Cognitive Level: Applying REF: pp. 383–384

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Psychosocial Integrity a. Assign a nursing assistant to feed the resident. b. Assign a nursing assistant to sit with the resident as the resident eats. c. Serve the resident finger foods. d. Serve the resident one dish at a time. e. Alter the dining ambience to reduce distractions.

4. A nurse in a long term care facility is concerned that a 94- year-old resident with dementia is losing weight. Upon assessment, the nurse notes that the resident, who is able to feed herself independently, consumes less than 50% of each of her meal trays. Which of the following strategies can the nurse utilize to improve this resident’s intake? (Select all that apply.)

ANS: B, C, D, E

Serving the resident finger foods and one dish at a time may improve the resident’s intake at meals. Assigning a nursing assistant to sit with the resident may also accomplish the goal, as this may help in reducing environmental distractions. Because the resident can feed herself, it is important to promote that level of independence for as long as possible. Assigning someone to feed the resident will impede her independence.

DIF: Cognitive Level: Applying REF: p. 401, Box 29-31

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Psychosocial Integrity a. Acute onset of symptoms or fluctuating course b. Inattention c. Disorganized thinking d. Altered level of consciousness e. Alteration in level of physical activity

5. A nurse is assessing an older patient with new onset confusion using the Confusion Assessment Method (CAM). The nurse understands that in order to have a diagnosis of delirium when using the CAM, the patient must exhibit which of the following? (Select all that apply.)

ANS: A, B

In order to be diagnosed with delirium, using the CAM, the individual must have acute onset or fluctuating course and inattention and either disorganized thinking or altered level of consciousness. Although individuals with delirium often have either hyperactivity or hypoactivity, this is not one of the criteria assessed on the CAM.

DIF: Cognitive Level: Understanding REF: p. 387, Box 29-8

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Psychosocial Integrity