Chapter 59:
instruct family members to
Dementia and
Delirium
Test Bank
MULTIPLE CHOICE
1. A 68-year-old patient who is
hospitalized with pneumonia is
disoriented and confused 3
days after
admission. Which information
indicates that the patient is
experiencing delirium rather
than dementia?
a. The patient was oriented
and alert when admitted.
b. The patients speech is
fragmented and incoherent.
c. The patient is oriented to
person but disoriented to
place and time.
d. The patient has a history of
increasing confusion over
several years.
ANS: A
The onset of delirium occurs
acutely. The degree of
disorientation does not
differentiate between delirium
and
dementia. Increasing
confusion for several years is
consistent with dementia.
Fragmented and incoherent
speech may occur with either
delirium or dementia.
2. Which intervention will the
nurse include in the plan of
care for a patient with
moderate dementia who had
an appendectomy 2 days
ago?
a. Provide complete personal
hygiene care for the patient.
b. Remind the patient
frequently about being in the
hospital.
c. Reposition the patient
frequently to avoid skin
breakdown.
d. Place suction at the
bedside to decrease the risk
for aspiration.
ANS: B
The patient with moderate
dementia will have problems
with short- and long-term
memory and will need
reminding about the
hospitalization. The other
interventions would be used
for a patient with severe
dementia,
who would have difficulty with
swallowing, self-care, and
immobility.
3. When administering a
mental status examination to a
patient with delirium, the nurse
should
a. wait until the patient is well-
rested.
b. administer an anxiolytic
medication.
c. choose a place without
distracting stimuli.
d. reorient the patient during
the examination.
ANS: C
Because overstimulation by
environmental factors can
distract the patient from the
task of answering the
nurses questions, these
stimuli should be avoided. The
nurse will not wait to give the
examination because
action to correct the delirium
should occur as soon as
possible. Reorienting the
patient is not appropriate
during
the examination. Antianxiety
medications may increase the
patients delirium.
4. The nurse is concerned
about a postoperative patients
risk for injury during an
episode of delirium. The most
appropriate action by the
nurse is to
a. secure the patient in bed
using a soft chest restraint.
b. ask the health care provider
to order an antipsychotic drug.
c.
remain with the patient and
prevent injury.
d. assign unlicensed assistive
personnel (UAP) to stay with
the patient and offer
reorientation.
ANS: D
The priority goal is to protect
the patient from harm. Having
a UAP stay with the patient
will ensure the patients safety.
Visits by family members are
helpful in reorienting the
patient, but families should not
be responsible for protecting
patients from injury.
Antipsychotic medications
may be ordered, but only if
other measures are not
effective because these
medications have many side
effects. Restraints are not
recommended because they
can increase the patients
agitation and disorientation.
5. A 56-year-old patient in the
outpatient clinic is diagnosed
with mild cognitive impairment
(MCI).Which action will the
nurse include in the plan of
care?
a. Suggest a move into an
assisted living facility.
b. Schedule the patient for
more frequent appointments.
c. Ask family members to
supervise the patient’s daily
activities.
d. Discuss the preventive use
of acetylcholinesterase
medications.
ANS: B
Ongoing monitoring is
recommended for patients
with MCI. MCI does not
interfere with activities of daily
living, acetylcholinesterase
drugs are not used for MCI,
and an assisted living facility
is not indicated for MCI.
6. The nurse is administering
a mental status examination to
a 48-year-old patient who has
hypertension. The nurse
suspects depression when the
patient responds to the nurses
questions with
a. Is that right?
b. I dont know.
c. Wait, let me think about
that.
d. Who are those people over
there?
ANS: B
Answers such as I dont know
are more typical of depression
than dementia. The response
Who are those people over
there? is more typical of the
distraction seen in a patient
with delirium. The remaining
two answers are more typical
of a patient with mild to
moderate dementia.
7. A 68-year-old patient is
diagnosed with moderate
dementia after multiple
strokes. During assessment of
the
patient, the nurse would
expect to find
a.excessive nighttime
sleepiness.
b.difficulty eating and
swallowing.
c.loss of recent and long-term
memory.
d. fluctuating ability to perform
simple tasks.
ANS: C
Loss of both recent and long-
term memory is characteristic
of moderate dementia.
Patients with dementia have
frequent nighttime awakening.
Dementia is progressive, and
the patients ability to perform
tasks would not
have periods of improvement.
Difficulty eating and
swallowing is characteristic of
severe dementia.
8.
Which action will help the
nurse determine whether a
new patients confusion is
caused by dementia or
delirium?
a.Administer the Mini-Mental
Status Exam.
b.Use the Confusion
Assessment Method tool.
c.Determine whether there is
a family history of dementia.
d.Obtain a list of the
medications that the patient
usually takes.
ANS: B
The Confusion Assessment
Method tool has been
extensively tested in
assessing delirium. The other
actions
will be helpful in determining
cognitive function or risk
factors for dementia or
delirium, but they will not be
useful in differentiating
between dementia and
delirium.
9. A 72-year-old female
patient is brought to the clinic
by the patients spouse, who
reports that she is unable to
solve common problems
around the house. To obtain
information about the patients
current mental status, which
question should the nurse ask
the patient?
a. Are you sad?
b. How is your self-image?
c. Where were you were
born?
d. What did you eat for
breakfast?
ANS: D
This question tests the
patients short-term memory,
which is decreased in the mild
stage of Alzheimers disease
or dementia. Asking the
patient about her birthplace
tests for remote memory,
which is intact in the early
stages. Questions about the
patients emotions and self-
image are helpful in assessing
emotional status, but they are
not as helpful in assessing
mental state.
10. A patient is being
evaluated for Alzheimers
disease (AD). The nurse
explains to the patients adult
children that
a. the most important risk
factor for AD is a family history
of the disorder.
b. new drugs have been
shown to reverse AD
dramatically in some patients.
c. a diagnosis of AD is made
only after other causes of
dementia are ruled out.
d. the presence of brain
atrophy detected by magnetic
resonance imaging (MRI) will
confirm the diagnosis of AD.
ANS: C
The diagnosis of AD is usually
one of exclusion. Age is the
most important risk factor for
development of AD. Drugs
may slow the deterioration but
do not reverse the effects of
AD. Brain atrophy is a
common finding in AD, but it
can occur in other diseases as
well and does not confirm a
diagnosis of AD.
11.
Which nursing action will be
most effective in ensuring
daily medication compliance
for a patient with mild
dementia?
a. Setting the medications up
monthly in a medication box
b. Having the patients family
member administer the
medication
c. Posting reminders to take
the medications in the patients
house
d. Calling the patient weekly
with a reminder to take the
medication
ANS: B
Because the patient with mild
dementia will have difficulty
with learning new skills and
forgetfulness, the most
appropriate nursing action is
to have someone else
administer the drug. The other
nursing actions will not be as
effective in ensuring that the
patient takes the medications.
12. A patient who has severe
Alzheimers disease (AD) is
being admitted to the hospital
for surgery. Which intervention
will the nurse include in the
plan of care?
a. Encourage the patient to
discuss events from the past.
b. Maintain a consistent daily
routine for the patients care.
c. Reorient the patient to the
date and time every 2 to 3
hours.
d. Provide the patient with
current newspapers and
magazines.
ANS: B
Providing a consistent routine
will decrease anxiety and
confusion for the patient.
Reorientation to time and
place will not be helpful to the
patient with severe AD, and
the patient will not be able to
read. The patient with severe
AD will probably not be able to
13. A 71-year-old patient with
Alzheimers disease (AD) who
is being admitted to a long-
term care facility hashad
several episodes of wandering
away from home. Which
action will the nurse include in
the plan of care?
a. Reorient the patient several
times daily.
b. Have the family bring in
familiar items.
c. Place the patient in a room
close to the nurses station.
d. Ask the patient why the
wandering episodes have
occurred.
ANS: C
Patients at risk for problems
with safety require close
supervision. Placing the
patient near the nurses station
will allow nursing staff to
observe the patient more
closely. The use of why
questions can be frustrating
for patients with AD because
they are unable to understand
clearly or verbalize the reason
for wandering behaviors.
Because of the patients short-
term memory loss,
reorientation will not help
prevent wandering behavior.
Because the patient had
wandering behavior at home,
familiar objects will not
prevent wandering.
14. The day shift nurse at the
long-term care facility learns
that a patient with dementia
experienced sundowning late
in the afternoon on the
previous two days. Which
action should the nurse take?
a. Keep blinds open during the
daytime hours.
b. Provide hourly orientation to
time and place.
c. Have the patient take a brief
mid-morning nap.
d. Move the patient to a
quieter room late in the
afternoon.
ANS: A
A likely cause of sundowning
is a disruption in circadian
rhythms and keeping the
patient active and in daylight
will help reestablish a more
normal circadian pattern.
Moving the patient to a
different room might increase
confusion. Taking a nap will
interfere with nighttime sleep.
Hourly orientation will not be
helpful in a patient with
dementia.
15. The nurses Initial action
for a patient with moderate
dementia who develops
increased restlessness and
agitation should be to
a. reorient the patient to time,
place, and person.
b. administer a PRN dose of
lorazepam (Ativan).
c. assess for factors that might
be causing discomfort.
d. assign unlicensed assistive
personnel (UAP) to stay in the
patients room.
ANS: C
Increased motor activity in a
patient with dementia is
frequently the patients only
way of responding to factors
like pain, so the nurses initial
action should be to assess the
patient for any precipitating
factors. Administration of
sedative drugs may be
indicated, but this should not
be done until assessment for
precipitating factors has been
completed and any of these
factors have been addressed.
Reorientation is unlikely to be
helpful for the patient with
moderate dementia. Assigning
UAP to stay with the patient
may also be necessary, but
any physical changes that
may be causing the agitation
should be addressed first.
16. When administering the
Mini-Cog exam to a patient
with possible Alzheimers
disease, which action will
the nurse take?
a. Check the patients
orientation to time and date.
b. Obtain a list of the patients
prescribed medications.
c. Ask the person to use a
clock drawing to indicate a
specific time.
d. Determine the patients
ability to recognize a common
object such as a pen.
ANS: C
In the Mini-Cog, patients
illustrate a specific time stated
by the examiner by drawing
the time on a clock face. The
other actions may be included
in assessment for Alzheimers
disease, but are not part of the
Mini-Cog exam.
17. Which hospitalized patient
will the nurse assign to the
room closest to the nurses
station?
a. Patient with Alzheimer’s
disease who has long-term
memory deficit
b. Patient with vascular
dementia who takes
medications for depression
c. Patient with new-onset
confusion, restlessness, and
irritability after surgery
d. Patient with dementia who
has an abnormal Mini-Mental
State Examination
ANS: C
This patients history and
clinical manifestations are
consistent with delirium. The
patient is at risk for safety
problems and should be
placed near the nurses’
station for ongoing
observation. The other
patients have chronic
symptoms that are consistent
with their diagnoses but are
not at immediate risk for
safety issues.
18. After change-of-shift
report on the Alzheimers
disease/dementia unit, which
patient will the nurse assess
first ?
a. Patient who has not had a
bowel movement for 5 days
b. Patient who has a stage II
pressure ulcer on the coccyx
c. Patient who is refusing to
take the prescribed
medications
d. Patient who developed a
new cough after eating
breakfast
ANS: D
A new cough after a meal in a
patient with dementia
suggests possible aspiration
and the patient should be
assessed immediately. The
other patients also require
assessment and intervention,
but not as urgently as a
patient with possible
aspiration or pneumonia.
MULTIPLE RESPONSES
1. The spouse of a 67-year-
old male patient with early
stage Alzheimers disease
(AD) tells the nurse, I
amexhausted from worrying
all the time. I dont know what
to do. Which actions are best
for the nurse to take
next(select all that apply)?
a. Suggest that a long-term
care facility be considered.
b. Offer ideas for ways to
distract or redirect the patient.
c. Teach the spouse about
adult day care as a possible
respite.
d. Suggest that the spouse
consult with the physician for
antianxiety drugs.
e. Ask the spouse what she
knows and has considered
about dementia care options.
ANS: B, C, E
The stress of being a
caregiver can be managed
with a multicomponent
approach. This includes
respite care,learning ways to
manage challenging
behaviors, and further
assessment of what the
spouse may already have
considered for care options.
The patient is in the early
stages and does not need
long-term placement.
Antianxiety medications may
be appropriate, but other
measures should be tried first.
2. Which nursing actions
could the nurse delegate to a
licensed practical/vocational
nurse (LPN/LVN) who is part
of the team caring for a patient
with Alzheimers disease
(select all that apply)?
a. Develop a plan to minimize
difficult behavior.
b. Administer the prescribed
memantine (Namenda).
c. Remove potential safety
hazards from the patients
environment.
d. Refer the patient and
caregivers to appropriate
community resources.
e. Help the patient and
caregivers choose memory
enhancement methods.
f. Evaluate the effectiveness
of the prescribed enteral
feedings on patient nutrition.
ANS: B, C
LPN/LVN education and
scope of practice includes
medication administration and
monitoring for
environmental safety in stable
patients. Planning of
interventions such as ways to
manage behavior or improve
memory, referrals, and
evaluation of the effectiveness
of interventions require
registered nurse (RN)level
education and scope of
practice.