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  1. A 73-year-old woman with pneumonia becomes agitated after being admitted to the intensivecare unit through the emergency department. She is placed in soft restraints when she continuesto try to leave her bed despite being too weak to walk. Her vital signs are erratic, and herthinking seems disorganized. During her first 24 hours in ICU, the patient varies from somnolentto agitated, and from laughing to angry. Her daughter reports that the patient “was never like thisat home.” What is the most likely explanation for the situation?

    A. The patient is experiencing delirium secondary to the pneumonia.
    B. The patient is sundowning due to the decreased stimulation of the intensive care unit.
    C. Pneumonia has worsened the patient’s early-stage dementia.
    D. The patient does not want to be in the hospital and is angry that staff will not let herleave.
    A. The patient is experiencing delirium secondary to the pneumonia.

    While pneumonia may result in hypoxia which could aggravate the symptoms of dementia, the patient’s daughter reports that this behavior is out of the ordinary. Delirium is always secondary to other disorders or causes (such as medications or fever), develops over a short period of time, and presents with emotional lability, unstable vital signs, fluctuating levels of consciousness, disorientation, and disorganized thinking—all of which exist in this case. The patient may well be angry about being hospitalized, but this would be an unlikely explanation forthe constellation of symptoms and the patient’s overall levels of mental deterioration sinceadmission. Sundown syndrome is the development or worsening of behavioral problems due toreduced sensory input and relative lack of orientation aids (e.g., lighting) and is characterized byincreasing disorientation as nightfall proceeds. In this case, the patient’s behavioral changes areoccurring and changing in a manner seemingly unrelated to the time of day (e.g., persistingthrough a 24-hour period).
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  2. Intervention(s) appropriate for a hospitalized patient experiencing delirium include which ofthe following? Select all that apply.

    1. Immediately placing the patient in restraints if she begins to hallucinate or act irrationally or unsafely
    2. Assuring that a clock and a sign indicating the day and date is displayed where the patientcan see it easily
    3. Being prepared for possible hostile responses to efforts to take vital signs or provide direct physical care
    4. Preventing sensory deprivation by placing the patient near the nurses’ station and leavingthe television and multiple lights turned on 24 hours per day
    5. Speaking with the patient frequently for short periods for reassurance, assisting thepatient in remaining oriented, and ensuring the patient’s safety
    6. Anticipating that the patient may try to leave if agitated and providing for continuousdirect observation to prevent wandering
    7. Promoting normalized sleep patterns by encouraging the patient to remain awake duringthe day and facilitating rest at night

    • Restraint use tends to increase the patient’s fear and resistance and should not be used unless all other options for reassuring the patient’s safety have failed.
    • Clocks and other items thathelp orient the patient can prevent or decrease the disorientation.
    • While not prone to violence, patients experiencing dementia may misinterpret the nurse’s intentions and respond aggressively with little or no warning, so to increase staff’s safety, caution is necessary when agitation is increasing.
    • Hospitals tend to provide excess stimulation, particularly if the patient is in a hightraffic area such as the nurses’ station. Some lighting is helpful round the clock in reducingdisorientation, but leaving the TV on 24 hours and placement near the station exposes the patientto excess noise and stimulation, which can be disorienting to a patient who is overloaded withsensory input. Speaking with the patient for frequent, brief periods allows for frequentreassessment and reorientation opportunities. It also helps to prevent isolation and disorientationwithout overstimulating the patient.
    • The risk of elopement should be anticipated and antielopementprecautions, such as direct observation or electronic monitors, should beimplemented.
    • Sleep patterns can become disrupted due to sleeping during the day (from sedationor boredom), which in turns interferes with sleep at night and increases the risk of sundowning; therefore, interventions which normalize sleep cycles are therapeutic.
  3. Which statement about dementia is accurate?

    A. People with dementia tend to be distressed by it and complain about its symptoms.
    B. Hypertension, diminished activity levels, and head injury increase the risk of dementia.
    C. Disorientation is the dominant and most disruptive symptom of dementia.
    D. The majority of people over age 85 are affected by dementia.
    B. Hypertension, diminished activity levels, and head injury increase the risk of dementia.

    Even among those 85 and older, the majority of persons are not significantly affectedby dementia, whose primary characteristics include the gradual, progressive loss of memory, cognitive functioning, and decision-making abilities.
    Although disorientation tends to result at some point in dementia, it is usually not the most dominant or fundamental feature of dementia.
    Dementia develops insidiously, and most persons with it fail to notice its development and tend to minimize or conceal the presence of symptoms rather than complain or seek assistance.
    Many factors can contribute to dementia in vulnerable persons, including diet, diminished physical and mental activity, and cardiovascular risk factors such as hypertension.
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  4. Which of the following intervention(s) would be beneficial for those caring for a loved onewith Alzheimer’s disease? Select all that apply.

    1. Guide the family to restrict the patient’s driving as soon as signs of forgetfulness areexhibited.
    2. Recommend switching to hospital-type gowns to facilitate bathing, dressing, and otherphysical care of the patient.
    3. Discourage wandering by installing complex locks or locks placed at the tops of doorswhere the patient cannot readily reach them.
    4. For situations in which the patient becomes upset, teach loved ones to listen briefly, provide support, and then change the topic.
    5. Encourage caregivers to care for themselves, as well as the patient, via use of support resources such as adult day care or respite care.
    6. If the patient is prone to wander away, encourage family to notify police and neighbors of the patient’s condition, wandering behavior, and description.

    • To preserve independence as long as possible, it is generally recommended that driving restrictions be implemented gradually—for example, initially discouraging only nighttime driving or arranging for another adult to be present in the car to monitor driving abilities.
    • Hospital gowns may offer some convenience but at a cost to the patient’s self-esteem; even for patients in professional care settings, the use of street clothing is encouraged to promote a sense of normalcy and wellbeing.
    • Locks the patient cannot reach or operate can reduce elopements and are helpful.
    • Listening, offering support, and then changing the topic are useful strategies for calming an upset loved one with dementia. Although changing the topic would not be therapeutic for most other patients, for the dementia patient it permits the individual to calm more readily than would continuing the focus on upsetting but nonnegotiable topics such as not being allowed to drive or to leave unaccompanied.
    • Caregivers who do not nurture and care forthemselves (e.g., through regular periods of respite from the caregiving role) soon run out oftheir reserves of physical and emotional energy, becoming both overwhelmed and less effective in their efforts to provide unrealistic amounts of care.
    • Although it may seem to be a violation of the patient’s confidentiality rights, involving neighbors and local emergency personnel is protective of a patient who is prone to wander. It increases the number of people who are able to identify quickly a wandering person with dementia and thus reduces the likelihood of awandering person coming to harm.
  5. Which problem is not considered a causative agent in delirium? 

    A. Infection
    B. Elevated blood urea nitrogen levels
    C. Antibiotic therapy
    D. Anticholinergic drugs
    C. Antibiotic therapy

    While delirium may be a result of an infection, antibiotic therapy is not know to cause cognitive disorders.Text pages: 371, 372
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  6. T/F: Perceptual distortion refers to impaired ability to process intellectual, sensory and emotional data in a logical meaningful way.
  7. Which event would a client with early (stage 1) Alzheimer's disease have greatest difficulty remembering?

    A. High school graduation
    B. CorrectWhat was eaten for breakfast
    C. The birth of one's children
    D. A story of a teenage escapade
    B. CorrectWhat was eaten for breakfast

    Initially, recent memory is impaired while remote memory remains intact.Text page: 382
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  8. T/F: Hallucinations are errors in the perception of a sensory stimulus.
    False: Illusions are
  9. T/F: Clients with delirium often misinterpret reality, perceiving threat where none actually exists. Delirious clients who are fearful may strike out at others, seemingly without provocation.
  10. Which cause of dementia has a clear genetic link?

    A. Creutzfeldt-Jacob disease
    B. Multiinfarct dementia
    C. Alzheimer's disease
    D. Dementia from advanced alcoholism
    C. Alzheimer's disease

    Family members of people with Alzheimer's disease have a risk of acquiring the disease that is higher than that of the general population.Text page: 380
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  11. A client with Alzheimer's disease looks confused when the phone rings and seems not to recognize what the stimulus is. He also cannot recall many common household objects by name, such as a pencil or glass. The nurse can document this as

    A. anhedonia.
    B. agnosia.
    C. aphasia.
    D. apraxia.
    B. agnosia.

    Agnosia is the loss of the ability to recognize familiar objects.Text page: 381
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  12. The family of a client with Alzheimer's disease mentions to the nurse that seeing his loss of function when he was once such a competent individual has been very difficult. A nursing diagnosis that might be considered for such a family would be

    A. ineffective family therapeutic regimen management.
    B. disabled family coping.
    C. ineffective denial.
    D. anticipatory grieving.
    D. anticipatory grieving.

    Anticipatory grieving involves working through potential loss.Text page: 385
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  13. T/F: Sundowning involves increased disorientation and agitation occurring at night.
  14. The nurse caring for a client with Alzheimer's disease can anticipate that the family will need information about therapy with

    A. antihypertensives.
    B. immunosuppressants.
    C. benzodiazepines.
    D. acetylcholinesterase inhibitors.
    D. acetylcholinesterase inhibitors.

    Memory deficit is thought to be related to a lack of acetylcholine at the synaptic level. Acetylcholinesterase inhibitor drugs prevent the chemical that destroys acetylcholine from acting, thus leaving more available acetylcholine.Text page: 394
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  15. Delirium is characterized by
    • a disturbance of consciousness
    • a change in cognition (such as impaired attention span)
    • a fluctuating level of consciousness that develop over a short period of time.

    Text page: 373
  16. A client is brought to the hospital by her daughter, who visited this morning and found her mother to be confused and disoriented. The daughter remembered to bring her mother's medication to the hospital. They include digoxin, an antihypertensive, a tricyclic antidepressant, and an antiparkinson drug (benztropine mesylate) that the client has been taking for only 5 days. For planning purposes, the nurse should realize that the least likely action the physician will take is

    A. suggesting the social worker talk to the family about institutionalization.
    B. having blood drawn for a serum digoxin level.
    C. withdrawing the antidepressant and antiparkinson drugs.
    D. ordering benzodiazepine administration.
    A. suggesting the social worker talk to the family about institutionalization.

    It is quite possible that the client's problem is delirium, which is a reversible disorder. Institutionalization should not be necessary.Text page: 371
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  17. T/F: During stage 1 Alzheimer's disease the client is aware of memory impairment and may attempt to disguise it or cover it by being evasive or using confabulation.

    Text pages: 382, 383
  18. An initial intervention the nurse might suggest to the family members of a client with Alzheimer's disease who has begun to be incontinent for urine is to:

    A. label the bathroom door with a picture.
    B. encourage hourly toileting.
    C. provide toileting on an as-needed basis.
    D. apply disposable diapers.
    A. label the bathroom door with a picture.

    Labeling doors and various items with pictures can be helpful for a client who has forgotten where things are and what certain items are. Text page: 388
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  19. A nurse is developing a plan of care for an older client with dementia and formulates a nursing diagnosis of aself-care deficit. The nurse develops which realistic outcome for the client?

    A. The client will function at the highest level of independence possible.
    B. The client will complete all activities of daily living independently within a 1- to 1-1/2 hour time frame.
    C. The nursing staff will attend to all of the client's activities of daily living needs during the hospital stay.
    D. The client will be admitted to a nursing home to have the needs of activities of daily living met.
    A. The client will function at the highest level of independence possible.

    All clients, regardless of age, need to be encouraged to perform at the highest level of independence possible. This contributes to the client's sense of control and well-being. Options 2 and 3 are not client-centered goals, and a 1- to 1-1/2 hour time frame may not be realistic for an older client with dementia.
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  20. An older adult client at the retirement center spits her food out and throws it on the floor. She yells, 'This turkey is dry and cold! I can't stand the food here!" How should the nurse respond to the client?

    A. "One of the things that was agreed upon was that anyone who did not useappropriate behavior would be asked to leave the dining room. Please leavenow."
    B. "Now look what you've done! You're ruining this meal for the whole community. Aren't you ashamed of yourself?"
    C. "Let me get you another serving that is more to your liking. Would you like to come visit the chef and select your own serving?"
    D. "I think you had better return to your apartment now. I'll make arrangements for a new meal to be served to you there."
    C. "Let me get you another serving that is more to your liking. Would you like to come visit the chef and select your own serving?"

    Asking the client to accompany the nurse to the kitchen respects the client's need for control, removes the angry client from the dining room, and may offer the nurse an opportunity to assess what is happening to the client. Option 2 could provoke a regressive struggle between the nurse and the client and cause more anger in the client. Option 1 is angry, aggressive, and nontherapeutic. In option 4, the nurse is authoritative, and it would not be appropriate to ask the client to leave. This action may set up an aggressive struggle between the nurse and the client.
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  21. Assessment for Delerium
    Acute onset and fluctuating levels of conciousness

    Delerium is always secondary to another physiological condition and is a transient disorder

    The major causes are nervous system disease, systemic disease (such as cardiac failure), postoperative states, and drug intoxicatiosn or withdrawals.
  22. Delirium, Dementia, Depression

    • Sudden, over hours to days
    • Slowly, over months
    • May have been gradual, withexacerbation during crisis orstress
  23. Delirium, Dementia, Depression

    Cause or contributing factors?
    Hypoglycemia, fever,dehydration, hypotension; infection, other conditions that disrupt body's homeostasis adverse drug reaction; head injury; change in environment (e.g., hospitalization); pain; emotional stress

    Alzheimer's disease,vascular disease, human immunodeficiency virus infection, neurological disease, chronic alcoholism, head trauma

    Lifelong history, losses, loneliness, crises, declining health, medical conditions
  24. Delirium, Dementia, Depression

    Level of consciousness?

    Not altered

    Not altered
  25. Evidence-Based Practice: Delerium & surgery
    Prophylactic haloperidol (Haldol) may reduce the severity and duration of symptoms for patients undergoing hip surgery.
  26. Diagnosis and outcomes for Delerium
  27. T/F: Dementia is irreversible
    False: Most are, but about 15% are due to reversible illness.
  28. Primary Dimentia is
    not secondary to any other disorder

    AD accounts for about 60% of these
  29. Confabulation is
    a defense mechanism used by AD patients.

    It is not lying, but rather an unconcious attempt to maintain self-esteem
  30. Perseveration is
    a defense mechanism used by AD patients.

    It is the repetition of phrases or bahavior.
  31. Cardinal symptoms of AD
    Loss of

    • Amnesia - memory
    • Aphasia - language
    • Apraxia - purposeful movement
    • Agnosia - sensory ability to recognize objects, e.g. auditory agnosia - the inability to recognize a car horn
    • Executive functioning - planning, organizing and abstract thinking
  32. AD Stage 1
    (Mild) forgetfulness

    • Shows short-term memory losses; loses things, forgets
    • Memory aids compensate: lists, routines, organization
    • Aware of the problem; concerned about lost abilities
    • Depression common—worsens symptoms
    • Not diagnosable at this time
  33. AD Stage 2
    (Moderate) confusion

    • Shows progressive memory loss; short-term memory impaired; memory difficulties interfere with all abilities
    • Withdrawn from social activities
    • Shows declines in instrumental activities of daily living (ADLs), such as money management, legal affairs, transportation, cooking, housekeeping
    • Denial common; fears "losing his or her mind"
    • Depression increasingly common; frightened because aware of deficits; covers up for memoryloss through confabulation
    • Problems intensified when stressed, fatigued, out of own environment, ill
    • Commonly needs day care or in-home assistance
  34. AD stage 3
    (Modersate to Severe) ambulatory dementia

    • Shows ADL losses (in order): willingness and ability to bathe, grooming, choosing clothing dressing, gait and mobility, toileting, communication, reading, and writing skills
    • Shows loss of reasoning ability, safety planning, and verbal communication
    • Frustration common; becomes more withdrawn and self-absorbed
    • Depression resolves as awareness of losses diminishes
    • Has difficulty communicating; shows increasing loss of language skills
    • Shows evidence of reduced stress threshold; institutional care usually needed
  35. AD stage 4
    (Late) end stage

    • Family recognition disappears; does not recognize self in mirror
    • Nonambulatory; shows little purposeful activity; often mute; may scream spontaneously
    • Forgets how to eat, swallow, chew; commonly loses weight; emaciation common
    • Has problems associated with immobility (e.g., pneumonia, pressure ulcers, contractures)
    • Incontinence common; seizures may develop
    • Most certainly institutionalized at this point
    • Return of primitive (infantile) reflexes
  36. AD Drugs
    acetylecholamin or cholinesterase inhibitors

    Modestly improves cognition, behavior and function. Slows disease  progression.

    Tacrine (Cognex) - no longer used extensively owing to hepatotoxicity

    Donepezil (Aricept) - is better tolerate; doages is only once a day and is preferred.
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2013-03-06 02:26:57
nur210e2 Cognitive Disorders

Cognitive Disorders
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