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Study Guide Book - Alzheimer's Disease, Dementia, and Delirium
Study Guide Book - Chapter 60
Terms in this set (23)
1. What manifestations of cognitive impairment are primarily characteristic of delirium (select all that apply)?
a. Reduced awareness
b. Impaired judgments
c. Words difficult to find
d. Sleep/wake cycle reversed
e. Distorted thinking and perception
f. Insidious onset with prolonged duration
ANS: a, d, e.
Manifestations of delirium include cognitive impairment with reduced awareness, reversed sleep/wake cycle, and distorted thinking and perception. The other options are characteristic of dementia.
2. Which statement accurately describes dementia?
a. Overproduction of β-amyloid protein causes all dementias.
b. Dementia resulting from neurodegenerative causes can be prevented.
c. Dementia caused by hepatic or renal encephalopathy cannot be reversed.
d. Vascular dementia can be diagnosed by brain lesions identified with neuroimaging.
The diagnosis of vascular dementia can be aided by neuroimaging studies showing vascular brain lesions along with exclusion of other causes of dementia. Overproduction of β-amyloid protein contributes to Alzheimer's disease (AD). Vascular dementia can be prevented or slowed by treating underlying diseases (e.g., diabetes mellitus, cardiovascular disease). Dementia caused by hepatic or renal encephalopathy potentially can be reversed.
3. A patient with Alzheimer's disease (AD) dementia has manifestations of depression. The nurse knows that treatment of the patient with antidepressants will most likely do what?
a. Improve cognitive function
b. Not alter the course of either condition
c. Cause interactions with the drugs used to treat the dementia
d. Be contraindicated because of the central nervous system (CNS)-depressant effect of antidepressants
Depression is often associated with AD, especially early in the disease when the patient has awareness of the diagnosis and the progression of the disease. When dementia and depression occur together, intellectual
deterioration may be more extreme. Depression is treatable and use of antidepressants often improves cognitive function.
4. For what purpose would the nurse use the Mini-Mental State Examination to evaluate a patient with cognitive impairment?
a. It is a good tool to determine the etiology of dementia.
b. It is a good tool to evaluate mood and thought processes.
c. It can help to document the degree of cognitive impairment in delirium and dementia.
d. It is useful for initial evaluation of mental status but additional tools are needed to evaluate changes in cognition over time.
The Mini-Mental State Examination is a tool to document the degree of cognitive impairment and it can be used to determine a baseline from which changes over time can be evaluated. It does not evaluate mood or thought processes but can detect dementia and delirium and differentiate these from psychiatric mental illness. It cannot help to determine etiology.
5. During assessment of a patient with dementia, the nurse determines that the condition is potentially reversible when finding out what about the patient?
a. Has long-standing abuse of alcohol
b. Has a history of Parkinson's disease
c. Recently developed symptoms of hypothyroidism
d. Was infected with human immunodeficiency virus (HIV) 10 years ago
Hypothyroidism can cause dementia but it is a treatable condition if it has not been long standing. The other conditions are causes of irreversible dementia.
6. The husband of a patient is complaining that his wife's memory has been decreasing lately. When asked for examples of her memory loss, the husband says that she is forgetting the neighbors' names and forgot their granddaughter's birthday. What kind of loss does the nurse recognize this to be?
b. Memory loss in AD
c. Normal forgetfulness
d. Memory loss in mild cognitive impairment
In mild cognitive impairment people frequently forget people's names and begin to forget important events. Delirium changes usually occur abruptly. In Alzheimer's disease the patient may not remember knowing a person and loses the sense of time and which day it is. Normal forgetfulness includes momentarily forgetting names and occasionally forgetting to run an errand.
7. The wife of a patient who is manifesting deterioration in memory asks the nurse whether her husband has AD. The nurse explains that a diagnosis of AD is usually made when what happens?
a. A urine test indicates elevated levels of isoprostanes
b. All other possible causes of dementia have been eliminated
c. Blood analysis reveals increased amounts of β-amyloid protein
d. A computed tomography (CT) scan of the brain indicates brain atrophy
The only definitive diagnosis of AD can be made on examination of brain tissue during an autopsy but a
clinical diagnosis is made when all other possible causes of dementia have been eliminated. Patients with AD may have β-amyloid proteins in the blood, brain atrophy, or
isoprostanes in the urine but these findings are not exclusive to those with AD.
8. The newly admitted patient has moderate AD. What does the nurse know this patient will need help with?
d. Self-care activities
In the moderate stage of AD, the patient may need help with getting dressed. In the severe stage, patients will be unable to dress or feed themselves and are usually incontinent.
9. What is one focus of collaborative care of patients with AD?
a. Replacement of deficient acetylcholine in the brain
b. Drug therapy for cognitive problems and undesirable behaviors
c. The use of memory-enhancing techniques to delay disease progression
d. Prevention of other chronic diseases that hasten the progression of AD
Because there is no cure for AD, collaborative management is aimed at controlling the decline in cognition, controlling the undesirable manifestations that the patient may exhibit, and providing support for the family caregiver. Anticholinesterase agents help to increase acetylcholine (ACh) in the brain but a variety of other drugs are also used to control behavior. Memory- enhancing techniques have little or no effect in patients with AD, especially as the disease progresses. Patients with AD have limited ability to communicate health symptoms and problems, leading to a lack of professional attention for acute and other chronic illnesses.
10. The patient is receiving donepezil (Aricept), lorazepam (Ativan), risperidone (Risperdal), and sertraline (Zoloft) for the management of AD. What benzodiazepine medication is being used to help manage this patient's behavior?
a. Sertraline (Zoloft)
b. Donepezil (Aricept)
c. Lorazepam (Ativan)
d. Risperidone (Risperdal)
Lorazepam (Ativan) is a benzodiazepine used to manage behavior with AD. Sertraline (Zoloft) is a selective serotonin reuptake inhibitor used to treat depression. Donepzil (Aricept) is a cholinesterase inhibitor used for decreased memory and cognition. Risperidone (Risperdal) is an antipsychotic used for behavior management.
11. What N-methyl-d-aspartate (NMDA) receptor antagonist is frequently used for a patient with AD who is experiencing decreased memory and cognition?
a. Trazodone (Desyrel)
b. Olanzapine (Zyprexa)
c. Rivastigmine (Exelon)
d. Memantine (Namenda)
Memantine (Namenda) is the N-methyl-d-aspartate (NMDA) receptor antagonist frequently used for AD patients with decreased memory and cognition. Trazodone (Desyrel) is an atypical antidepressant that may help with sleep problems. Olanzapine (Zyprexa) is an antipsychotic medication used for behavior management. Rivastigmine (Exelon) is a cholinesterase inhibitor used for decreased memory and cognition.
12. A patient with AD in a long-term care facility is wandering the halls very agitated, asking for her "mommy" and crying. What is the best response by the nurse?
a. Ask the patient, "Why are you behaving this way?"
b. Tell the patient, "Let's go get a snack in the kitchen."
c. Ask the patient, "Wouldn't you like to lie down now?"
d. Tell the patient, "Just take some deep breaths and calm down."
Patients with moderate to severe AD frequently become agitated but because their short-term memory loss is so pronounced, distraction is a very good way to calm them. "Why" questions are upsetting to them because they don't know the answer and they cannot respond to normal relaxation techniques.
13. The sister of a patient with AD asks the nurse whether prevention of the disease is possible. In responding, the nurse explains that there is no known way to prevent AD but there are ways to keep the brain healthy. What is included in the ways to keep the brain healthy (select all that apply)?
a. Avoid trauma to the brain.
b. Recognize and treat depression early.
c. Avoid social gatherings to avoid infections.
d. Do not overtax the brain by trying to learn new skills.
e. Daily wine intake will increase circulation to the brain.
f. Exercise regularly to decrease the risk for cognitive decline.
ANS: a, b, f.
Avoiding trauma to the brain, treating depression early, and exercising regularly can maintain cognitive function. Staying socially active, avoiding intake of harmful substances, and challenging the brain to keep its connections active and create new ones also help to keep the brain healthy.
14. The son of a patient with early-onset AD asks if he will get AD. What should the nurse tell this man about the genetics of AD?
a. The risk of early-onset AD for the children of parents with it is about 50%.
b. Women get AD more often than men do, so his chances of getting AD are slim.
c. The blood test for the ApoE gene to identify this type of AD can predict who will develop it.
d. This type of AD is not as complex as regular AD, so he does not need to worry about getting AD.
The risk of early-onset AD for the children of parents with it is 50%. Women do get AD more often than men but that is more likely related to women living longer than men than to the type of AD. ApoE gene testing is used for research with late-onset AD but does not predict who will develop the disease. Late-onset AD is more genetically
complex than early-onset AD and is more common in those over age 60 but because his parent has early-onset AD he is at a 50% risk of getting it.
15. A patient with moderate AD has a nursing diagnosis of impaired memory related to effects of dementia. What is an appropriate nursing intervention for this patient?
a. Post clocks and calendars in the patient's environment.
b. Establish and consistently follow a daily schedule with the patient.
c. Monitor the patient's activities to maintain a safe patient environment.
d. Stimulate thought processes by asking the patient questions about recent activities.
Adhering to a regular, consistent daily schedule helps the patient to avoid confusion and anxiety and is important both during hospitalization and at home. Clocks and calendars may be useful in early AD but they have little meaning to a patient as the disease progresses. Questioning the patient about activities and events they cannot remember is threatening and may cause severe anxiety. Maintaining a safe environment for the patient is important but does not change the disturbed thought processes.
16. The family caregiver for a patient with AD expresses an inability to make decisions, concentrate, or sleep. The nurse determines what about the caregiver?
a. The caregiver is also developing signs of AD.
b. The caregiver is manifesting symptoms of caregiver role strain.
c. The caregiver needs a period of respite from care of the patient.
d. The caregiver should ask other family members to participate in the patient's care.
Family caregiver role strain is characterized by such symptoms of stress as the inability to sleep, make decisions, or concentrate. It is frequently seen in family members who are responsible for the care of the patient with AD. Assessment of the caregiver may reveal a need for assistance to increase coping skills, effectively use community resources, or maintain social relationships. Eventually the demands on a caregiver exceed the resources and the person with AD may be placed in an institutional setting.
17. The wife of a man with moderate AD has a nursing diagnosis of social isolation related to diminishing social relationships and behavioral problems of the patient with AD. What is a nursing intervention that would be appropriate to provide respite care and allow the wife to have satisfactory contact with significant others?
a. Help the wife to arrange for adult day care for the patient.
b. Encourage permanent placement of the patient in the Alzheimer's unit of a long-term care facility.
c. Refer the wife to a home health agency to arrange daily home nursing visits to assist with the patient's care.
d. Arrange for hospitalization of the patient for 3 or 4 days so that the wife can visit out-of-town friends and relatives.
Adult day care is an option to provide respite for caregivers and a protective environment for the patient during the early and middle stages of AD. There are also in-home respite care providers. The respite from the demands of care allows the caregiver to maintain social contacts, perform normal tasks of living, and be more responsive to the patient's needs. Visits by home health
nurses involve the caregiver and cannot provide adequate respite. Institutional placement is not always an acceptable option at earlier stages of AD, nor is hospitalization available for respite care.
18. The health care provider is trying to differentiate the diagnosis of the patient between dementia and dementia with Lewy bodies (DLB). What observations by the nurse support a diagnosis of DLB (select all that apply)?
b. Fluctuating cognitive ability
c. Disturbed behavior, sleep, and personality
d. Symptoms of pneumonia, including congested lung sounds
e. Bradykinesia, rigidity, and postural instability without tremor
ANS: b, e. Dementia with Lewy bodies (DLB) is diagnosed with dementia plus two of the following symptoms: (1) extrapyramidal signs such as bradykinesia, rigidity, and postural instability but not always a tremor, (2) fluctuating cognitive ability, and (3) hallucinations. The extrapyramidal signs plus tremors would more likely indicate Parkinson's disease. Disturbed behavior, sleep, personality, and eventually memory are characteristics of frontotemporal lobe degeneration (FTLD).
19. Delegation Decision: The RN in charge at a long-term care facility could delegate which activities to unlicensed assistive personnel (UAP) (select all that apply)?
a. Assist the patient with eating.
b. Provide personal hygiene and skin care.
c. Check the environment for safety hazards.
d. Assist the patient to the bathroom at regular intervals.
e. Monitor for skin breakdown and swallowing difficulties.
ANS: a, b, d.
All caregivers are responsible for the patient's safety. Basic care activities, such as those associated with personal hygiene and activities of daily living (ADLs) can be delegated to unlicensed assistive personnel (UAP). The RN will perform ongoing assessments and develop and revise the plan of care as needed. The RN will assess the patient's safety risk factors, provide education, and make referrals. The licensed practical nurse (LPN) could check the patient's environment for potential safety hazards.
20. A 72-year-old woman is hospitalized in the intensive care unit (ICU) with pneumonia resulting from chronic obstructive pulmonary disease (COPD). She has a fever, productive cough, and adventitious breath sounds throughout her lungs. In the past 24 hours her fluid intake was 1000 mL and her urine output was 700 mL. She was diagnosed with early-stage AD 6 months ago but has been able to maintain her activities of daily living (ADLs) with supervision. Identify at least six risk factors for the development of delirium in this patient.
ANS: a. Age; b. infection; c. hypoxemia (lung disease); d. intensive care unit (ICU) hospitalization (change in environment, sensory overload); e. preexisting dementia; f. dehydration. Also: hyperthermia and potentially medications to treat chronic obstructive pulmonary disease (COPD) and pneumonia.
21. A 68-year-old man is admitted to the emergency department with multiple blunt trauma following a one-vehicle car accident. He is restless; disoriented to person, place, and time; and agitated. He resists attempts at examination and calls out the name "Janice." Why should the nurse suspect delirium rather than dementia in this patient?
a. The fact that he wouldn't have been allowed to drive if he had dementia
b. His hyperactive behavior, which differentiates his condition from the hypoactive behavior of dementia
c. The report of emergency personnel that he was noncommunicative when they arrived at the accident scene
d. The report of his family that although he has heart disease and is "very hard of hearing," this behavior is unlike him
Delirium is an acute problem that usually has a rapid onset in response to a precipitating event, especially when the patient has underlying health problems, such as heart disease and sensory limitations. In the absence of prior cognitive impairment, a sudden onset of confusion, disorientation, and agitation is usually delirium. Delirium may manifest with both hypoactive and hyperactive symptoms.
22. What should be included in the management of a patient with delirium?
a. The use of restraints to protect the patient from injury
b. The use of short-acting benzodiazepines to sedate the patient
c. Identification and treatment of underlying causes when possible
d. Administration of high doses of an antipsychotic drug such as haloperidol (Haldol)
Care of the patient with delirium is focused on identifying and eliminating precipitating factors if possible. Treatment of underlying medical conditions, changing environmental conditions, and discontinuing medications that induce delirium are important. Drug therapy is reserved for those patients with severe agitation because the drugs themselves may worsen delirium
23. When caring for a patient in the severe stage of AD, what diversion or distraction activities would be appropriate?
a. Watching TV
b. Playing games
c. Books to read
d. Mobiles or dangling ribbons
In the severe stage of AD, the patient is at a developmental level of 15 months or less; therefore appropriate distractions would be infant toys. Watching TV and playing games are more appropriate in the mild stage. Books to read would need to be at developmentally appropriate levels to be used as a diversion.
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