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An elderly woman's husband died. When her brother arrives for the funeral, he notices her short-term problems & occasional disorientation. A few wks later, she calls him to say that her husband just died. She says "I didnt know he was so sick" Why did he die now?" She also complains of not sleeping and unrinary frequency and burning, and seeing rats in the kitchen. A homecare nurse is sent to evaluate her situation and finds the woman reclusive and passive, but pleasant. The nurse calls the woman's primary care physician to discuss the clien't situation and background, and give his assessment and recommendations. The nurse concludes that the woman:
1. Is experiencing the onset of alzheimer's disease
2. Is having trobule adjusting to living alone without her husband
3. is having delayed grieving related to her Alzheimer's disease
4. Is esperiecing delirium and a urinary tract infection
- 4. Is experiencing delirium and a urinary tract infection
- Rational: Delirium is commonly due to a medical condition such as a UTI in the elderly. Delirium often involves memory problems, disorientation, and hallucinations. It develops rather quickly. There is not enough data to support Alzheimer's disease especially with the quick onset of symptoms.
In planning for the discharge of a client with a cognitive disorder, it is important to assess the client's caregiver support system. Which aspects are the more crucial to assess? Select all that apply.
1. Availability of resources for caregiver support.
2. Ability to provide the level of care and supervision needed by the client.
3. Willingness to transport the client to medical and psychiaric services.
4. Interest in engaging the cognitively disoriented family member in reminiscence and games
5. Willingness to install door alarms and make other safety changes.
6. Understanding the client's abilities and limitations.
- It is important for a caregiver to have support for herself as well as be able to provide adequate safety, supervision, and medical care to the client. The caregiver must also have realistic expectations of the client, given his abilites and limitations. Reminiscing and engaging the client in games is desirable but not crucial to care.
The son of an elderly client who hs cognitive impairments approaches the nurse and says, I'm so upset. The physician says I have 4 days to decide on where my dad is going to live." The nurse responds to the son's concerns, gives him a list of types of living arrangements, and discusses the needs, abilities, and limitations of the client. The nurse should intervene further if the son makes which comment?
1. "Boy, I have a lot to think about before I see the social worker tomorrow."
2. "I think I can handle mose of Dad's needs wit the help of some home health care.'
3. "I'm so afraid of making the wrong decision, but I can move him later if I need to."
4. "I want the social worker to make this decision so Dad won't blame me."
4. Expecting the social worker to make the decision indicates that the son is avoiding participating in decisions about his father. The other responses convey that the son understands the importance of a careful decision, the availabiltiy of resources, and the ability tomake new plans if needed.
Transfer date for a client brought by ambulance to the hospital's psychiatric unit from a nursing home indicate that the client has become increasingly confused and disoriented. The client's behavior is found to be the result of cerebral arteriosclerosis. Which of the following behaviors of the nursing staff should positively influence the client's behavior? Select all that apply
1. Limiting the client's choices
2. Accepting the client as he is
3.Allowing the client to do as he wishes
4. Acting nonchalantly
5. Explaining to the client what he needs to do step-by-step
- Confused clients need fewer choices, acceptance as a person, and step-by-step directions. Allowing the client to do as he wishes can lead to substandard care and the risk of harm. Acting nonchalantly conveys a lack of caring.
The nurse observes a client in a group who is reminiscing about his past. Which effect should the nurse expect reminiscing to have on the client's functioning in the hospital?
1. Increase the cient's confusion and disorientation
2. Cause the client to become sad.
3. Decrease the client's feelings of isolatin and loneliness.
4. Keep the client from participating in therapeutic activities.
- Reminiscing can help reduce depression in an elderly client and lessens feelings of isolation and loneliness. Reminiscing encourages a focus on positive memories and accomplishments as well as shared memories with other clients. An increase in confusion and disorientation is most likely the result of other cognitive and situational factors, such as loss of short term memory, not reminiscing. The client will not liely become sad because reminiscing helps the client connect with positive memories. Keept the client from participating in therapeutive activities is less liely with reminiscing.
A 69-year-old client is admitted and diagnosed with delirium. Later in the day, he tries to get out of the locked unit. He yells, "Unlock this door. I've got to go see my doctor. I just can't miss my monthly Friday appointment." Which of the followng responses by the nurse is most appropriate?
1. "Please come away from the door. I'll show you your room."
2. "It's Tuesday and you are in the hospital. I'm Anna, a nurse."
3. "The door is locked to keep you from getting lost."
4. "I want you to come eat your lunch before you go see the doctor."
- Loss of orientation, especially for time and place, is common in delirium. The nurse should orient the client by telling him the time, date, place, and who the client is with. Taking the client to his room and telling him why the door is locked does not address his disorientation. Telling the client to eat before going to the doctor reinforces his disorientation.
An 83-year old woman is admitted to the unit after being examined in the emergency department (ED) and diagnosed with delirium. After the admission interviews with the client and her grandson, the nurse expalins that there will be more laboratory test and X-rays done that day. The grandson says, "She has already been stuck several times and had a brain scan or something. Just give her some medicine and let her rest." The nurse should tell the grandson whic of the following? Select all that apply
1. "I agree she needs to rest, but thre is no one specific medicine for your grandmother's condition."
2. "The doctor will look at ther results of those tests in the ED and decide what other tests are needed.
3. "Delirium commonly results from underlying medical causes that we need to identify and correct."
4. Tell me about your grandmother's behaviors and maybe I could figure out what medicine she needs."
5. "I'll ask the doctor to postpone more tests until tomorrow."
- The client does need rest and it is true that there is no specific medicine for delirium, but it is crucial to identify and treat the underlying causes of delirium. Other tests will be based on the results of already complete tests. Although some medications may be prescribed to help the client with her behaviors, this is not the primary basis for medication orders. Because the underlying medical causes of delirium could be fatal, treatment must be initiated as soon as possible. It is not the nurse's role to determine medications for this client. Postponing tests until the next day is inappropriate.
The nurse is attempting to draw blood from a woman with a diagnosis of delirium who was admitted last evening. The client yells out, "Stop; leave me alone. What are you trying to do to me? What's happening to me?" Which response by the nurse is most appropriate?
1. "The tests of your blood will help us figure out what is happening to you."
2. "Please hold still so I don't have to stick you a second time.
3. "After I get your blood, I'll get some medicaton to help you calm down."
4. "I'll tell you everything after I get your blood tests to the laboratory
- 1 "The tests of your blood will help us figure out what is happening to you."
- Explaining why blood is being taken responds to the client's concerns or fears about what is happening to her. Threatening more pain or promising to explain later ignores or postpones meeting the client's need for information. The client's statements do not reflect loss of self control requiring medication intervention.
A 90-year-old client diagnosed with major depression is suddenly experiencing sleep disturbances, inability to focus, poor recent memory, altered perceptions, and disorientation to time and place. Lab results indicate the client has a urinary tract infection and dehydration. After explaing the situation and giving the background and assessment data, the nurse should make which of the following recommendations to the client' physician?
1. An order to place the client in restraints.
2. A reevaluation of the client's mental status
3. The transfer of the client to a mendical unit
4. A transfer of the client to a nursing home.
- 3 A transfer of the client ot a medical unit
- The client is showing symptoms of delirium, a common outcome of UTI in older adults. The nurse can request a transfer to a medical unit for acute medical intervention. The client's symptoms are not just due to a worsening of the depression. There are not indications that the client needs restraints or a transfer to a nursing home at this point.
When caring for the client diagnoses with delirum, which conditionis the most important for the nurse to investigate?
1. Cancer of any kind.
2. Impaired hearing
3. Prescription drug intoxication
4. Heart failure
- 3 Prescription drug intoxication
- Polypharmacy is much more common in the elderly. Drug interactions increase the incidence of intoxication from prescribed medications, expecially with combinations of analgesics, digoxin, diuretics, and anticholinergics. With drug intoxication, the onset of the delirium typically is quick. Although cancer, impaired hearing, and heart failure could lead to delirium in the elderly, the onset would be more gradual.
In addition to developing over a period of hours or days, the nurse should assess delirium as distinguishable by whic of the following characteristics?
1. Disturbances in cognition and consciousness that fluctuate during the day.
2. The failure to identify objects despite intact sensory functions
3. Significant impairment in social or occupational function over time.
4. Memory impairment to the degree of being call amnesia.
- 1 Disturbances in cognition and consciousness that fluctuate during the day
- Fluctuating symptons are characteristic of delirium. The failure to identify objects despite intact sensory functions, significant impairment in social or occupational functioning over time, and memory impairment to the degree of being called amnesia all indicate dementia.
Which of the following is essential when caring for a client who is expericeing delirium?
1. Controlling behavioral symptoms with low-dose psychotropics
2. Identifying the underlying causative condition or illness
3. Manipulating the environment to increse orientation.
4. Decreasing or discontinuing all previously prescribed medications.
- 2 Identifying the underlying causative condition or illness
- The most critical aspect when caring for the client with delirium is to institute measures to correct the underlying causative condition or illness.. Controlling behavioral symptons with low-dose psychotropics, manipulating the environment, and decreasing or discontinuing all medications may be dangerous to the client's health.
Which of the following is a realistic, short-term goal to be accomplished in 2 to 3 days for a client with delirium?
1. Explain the experience of having delirium
2. Resume a normal sleep-wake cycle
3. Regain orientation to time and place
4. Establish normal bowel and bladder function.
- 3 Regain orientation to time and place
- In approximately 2 to 3 days, the client should be able to regain orientation and thus become oriented to time and place. Being able to explain the experience of having delirium is something that the client is expected to achieve later in the couse of the illness, but ultimately before discharge. Resuming a normal sleep-wake cycle and establishing normal bowel and bladder function probably will take longer, depending on how long it takes to resolve the underlying condition.
Which of the following should the nurse expect to include as a priority in the plan of care for a client with delirium based on the nurse's understanding about the disturbances in orientation associated with this disorder?
1. Identifying self and amking sure that the nurse has the client's attention
2. Eliminating the client's napping in the daytime as much as possible
3. Engaging the client in reminiscing with relatives or visitors.
4. Avoiding arguing with a suspicious client about his perceptions of reality.
- 1 Identifying self and making sure that the nurse has the client's attention
- Identifying oneself and making sure that the nurse has he client's attention addresses the difficulties with focusing, orientation, and maintaing attention. Elimination daytime napping is unrealistic until the cause of the delirium is determined and the client's ability to focus and maintain attention improves. Engaging the client in reminiscing and avoiding arguing are also unrealistic at this time.
A client has been in the critical care unit for 3 days following a severe myocardial infarction. Although he is medically stable, he has begun to have fluctuating episodes of consciousness, illogical thinking, and anxiety. He is picking at the aire to "catch these baby angels flying around my head" While waiting for medical and psychiatric consults, the nurse must intervene with the client's needs. Which of the following needs have the highest priority? Select all that apply.
1. Decreasing as much "foriegn" stimuli as possible
2. Avoiding challenging the client's perceptions about "baby angels"
3. Orienting the client about his medical conditin
4. Gently presenting reality as needed
5. Calling the client's family to report his onset of dementia.
- The abnormal stimuli of the critical care unit can aggravate the symptoms of delirium. Arguing with hallucinations is inapproproate. When a client has illogical thinking, gently presenting reality is appropriate. Dementia is not the likely cause of the client's symptoms. The client is experiencing delirium, not dementia.
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