Deck 22: Confusion

Question 1

While a nurse is dressing a patient with dementia as a result of Huntington disease,the patient states,"I don't want to wear clothes today," and begins to resist help putting on her clothes.The nurse's best action would be to:

A) Tell the patient that she must wear clothes or she cannot see her family later.
B) Get another nurse to help her force the patient to get dressed.
C) Talk to the patient about her family coming this afternoon, and continue to assist the patient gently with dressing.
D) Let the patient go without clothes, but make her stay in her room.

Answer 1

Talk to the patient about her family coming this afternoon, and continue to assist the patient gently with dressing.

Question 2

The nurse in a long-term care facility is taking patients to the dining room for lunch.She asks the patient who has been diagnosed with delirium if she is ready to go eat lunch.When the patient does not respond,the nurse should:

A) Take the patient by the arm and lead her to the dining room.
B) Assist the patient to bed, and bring her lunch to her.
C) Tell the patient that she can go to the dining room whenever she gets hungry.
D) Ask the patient again if she is ready to go eat lunch.

Answer 2

Ask the patient again if she is ready to go eat lunch.

Question 3

The family of a patient with Alzheimer disease asks the nurse,"When will my mother quit being so confused?" The nurse's response should be based on the fact that dementia is a:

A) Short-term confusional state that is typically reversible
B) State of confusion caused primarily by medications
C) State of confusion that usually begins abruptly and lasts a short period
D) Syndrome that is chronic and irreversible

Answer 3

Syndrome that is chronic and irreversible

Question 4

When admitting a patient who has recently become confused,the nurse asks the family for a list of all the medications that the patient is currently taking.The nurse is aware that the medication that could be causing confusion is:

A) Amoxicillin
B) Acetaminophen
C) Furosemide
D) Digoxin

Question 5

The Cognitive Developmental Approach (CDA)to caring for patients with dementia adapts interventions that are designed to:

A) Increase cognitive abilities
B) Adapt environment to patient
C) Offer a wide variety of choices
D) Abolish irrational fears

Question 6

The nurse is gathering information from the family of a patient who is experiencing confusion.An important question the nurse should ask the family is:

A) "Are you sure she is confused? Maybe she just didn't hear what you were saying."
B) "When did you first think she might be confused? Tell me exactly what happened."
C) "Did something bad happen to her during her childhood?"
D) "How can you say she is confused? She knows who she is."

Question 7

A patient has been admitted with a diagnosis of confusion.The physician's admission note states that he wants to assess for delirium versus dementia.The nurse knows that the main differences are:

A) Delirium usually lasts several years, whereas dementia lasts only a few days.
B) Delirium usually has sudden onset and is reversible, whereas dementia is chronic and irreversible.
C) Dementia is usually caused by medications, whereas delirium is not.
D) Dementia is easily treated with reality orientation, whereas delirium is not.

Question 8

The nurse is planning for the nutritional needs of a patient with Alzheimer disease.The best plan is to have the dietary department provide:

A) Pureed diet to be fed with a syringe
B) Foods that the patient can cut up to keep busy and not lose interest in eating
C) Finger foods, several times a day
D) High-protein liquid diet

Question 9

Reality orientation is helpful for some patients with confusion.The nurse should use this technique on a patient diagnosed with:

A) Organic brain syndrome
B) Senile dementia
C) Senility
D) Acute confusional state

Question 10

When assisting the patient with dementia to dress,the nurse's first action should be to:

A) Hand the patient her clothes, and ask her to put them on.
B) Hand the patient each article of clothing separately, and ask her to put it on.
C) Assist her with each article, giving specific instructions such as, "Put your arm in this hole."
D) Put the patient's clothes on without assistance from the patient.

Question 11

The nurse has found the patient with delirium in other patients' rooms several times.The best action by the nurse would be to:

A) Firmly tell the patient that he must stay out of other patients' rooms, and tell him to return to his room.
B) Take him back to his room, and put him in bed with the side rails up.
C) Take him to the nurses' station, and let him visit for a while.
D) Administer a dose of lorazepam (Ativan) as ordered.

Question 12

The patient with delirium repeatedly cries out for her husband.The first intervention by the nurse would be to:

A) Administer Haldol as ordered.
B) Apply restraints so that the patient will not harm herself.
C) Calmly tell the patient that she is in the hospital and that her husband is not there.
D) Call the husband, and tell him that he needs to come and stay with his wife.

Question 13

When teaching family members to care for the patient with dementia,the nurse must be sure that they understand two important concepts,which are that the patient usually:

A) Forgets things relatively quickly and is usually unable to learn new things.
B) Can remember new tasks but will forget any previously taught tasks.
C) Cannot learn new information but will probably remember anything you ask about the past.
D) Responds well to reality orientation and needs to have a flexible schedule.

Question 14

The patient asks the nurse what causes dementia.The nurse's response would be based on the understanding that the two most prevalent types of dementia are:

A) Pick disease and Huntington disease.
B) Alzheimer disease and vascular dementia.
C) Creutzfeldt-Jakob disease and Pick disease.
D) Vascular dementia and Huntington disease.

Question 15

The family of a patient with dementia expresses concern to the nurse about the patient wandering at night.They are afraid that the patient might get up while they are sleeping and go outside.The nurse's best advice would be to have them:

A) Apply a vest restraint at night.
B) Perform constant reality orientation.
C) Learn some behavior modification techniques.
D) Put new locks on the outside doors in new places.

Question 16

In assessing a patient for the possibility of confusion,the nurse should keep in mind that the two major types of confusion are:

A) Acute and chronic senility
B) Temporary and permanent confusion
C) Delirium and dementia
D) Senility and senile dementia

Question 17

A patient's presentation included confusion,which began very suddenly and lasted less than a week.The nurse should be able to identify this as:

A) Dementia
B) Acute confusion
C) Symptoms of Huntington disease
D) Senile dementia

Question 18

When admitting a patient who has been diagnosed as having confusion,the most important observation that the nurse should make is the patient's:

A) Eating, drinking, and sleeping patterns
B) Behavior, orientation, memory, and sleeping habits
C) Urinary and bowel elimination habits
D) Talking, walking, and sleeping patterns

Question 19

When assessing the patient for delirium versus dementia,the nurse would expect the patient with dementia to have signs of a(n):

A) Intermittent fear affect
B) Perplexity affect
C) Bewilderment affect
D) Flat affect

Question 20

The nurse is taking a patient who has Alzheimer disease to the bathing room for a tub bath.The patient states,"Please don't make me take a bath today.I am so afraid that I will be washed down the drain." The nurse's best response would be:

A) "Don't be silly, there's no way you would fit in the drain."
B) "I am your nurse, and I will stay with you, so you shouldn't be afraid of your bath."
C) "Let's go back to your room, and I will bathe you there."
D) "Today is your day for a bath."

Question 21

Although unclear,it is believed that Alzheimer disease is caused by:

A) Amyloid deposits in the brain
B) Excess of acetylcholine
C) Neurofibrillary tangles
D) Infiltration of Lewy bodies
E) Series of small strokes

Question 22

The nurse is discussing home care of the patient with dementia with the patient's family.The nurse should advise the family to prevent the patient from wandering by:

A) Applying a vest restraint to keep the patient in bed or in a chair.
B) Putting locks on any doors that it would be dangerous for the patient to open (e.g., outside doors, medicine cabinet).
C) Having someone remind the patient at least every 2 hours that he or she must not go outside by him or herself.
D) Setting up a reward system for the times the patient stays where the family has requested.

Question 23

When a normally oriented 87-year-old resident in a long-term care facility exhibits acute confusion,the nurse should first assess for a(n)____________________.

Question 24

The nurse will focus nursing care support for a patient with mild cognitive impairment (MCI)on:

A) Reorienting the patient to the physical environment.
B) Developing strategies to improve memory.
C) Assisting with dressing and eating.
D) Establishing toileting schedules.

Question 25

An older adult long-term care resident with dementia becomes agitated each evening after supper because he has not walked his dog.The nurse plans to intervene by doing the following: (Prioritize these options from the most simple to the most complex.)

A) Remind him that his dog is not in the facility.
B) Help him draw a dog on paper and carry it with him.
C) Give him a small stuffed dog.
D) Reorient the resident to the time and place.
E) Ask his daughter to bring the dog to the facility.

Question 26

The 80-year-old woman who has Alzheimer disease is restless,wanders during mealtime,and will not sit down to eat.The nurse assisting with writing the care plan prioritizes the following interventions for the goal-The patient will eat at least 25% of each meal: (Prioritize the options in sequence,from the most therapeutic to the least therapeutic)

A) Place her in a chair with a vest restraint.
B) Assign an nursing assistant (NA) to feed her.
C) Give her a high-protein drink in a small cup to carry with her.
D) Offer peanut butter crackers as she passes by.
E) Leave her alone. She will eat when she is hungry.

Question 27

The patient asks the nurse,"My doctor says I get confused sometimes because I have vascular dementia.What caused me to have that?" The most appropriate response by the nurse would be:

A) "It is usually caused from damage to brain cells because of inadequate blood supply, like a small stroke."
B) "It is probably just some abnormal electrical activity in your brain."
C) "You probably have a brain tumor."
D) "I'm sure he will explain it to you later."

Question 28

The nurse caring for the patient with dementia notices that the patient stays awake most of the night.The nurse's most appropriate action would be to:

A) Give a prescribed sleeping medication.
B) Tell the patient that it is nighttime, and that she must go to sleep.
C) Check the patient's record to see whether she is sleeping during the day.
D) Put the patient to bed, and put the side rails up.

Question 29

The 80-year-old patient with delirium related to high fever is hallucinating about large animals being in the room.The nurse's most reassuring response to this patient would be:

A) "Yes, the animals are in here but they are sound asleep."
B) "I'm going to turn out the lights so that you won't have to look at the animals."
C) "You are in the hospital. There are no animals in this room."
D) "The hospital does not allow animals in the room."

Question 30

The nurse is preparing a room for a patient being transferred from the emergency department with a diagnosis of delirium.The nurse should ensure that the room is:

A) Brightly lit
B) Shared by another patient
C) Visible from the nurses' station
D) Dark and quiet