The daughter of a patient with early familial Alzheimer's disease (AD) asks how AD is different from forgetfulness. You describe early warning signs of AD, including
a. Forgetting a colleague's name at a party
b. Repeatedly misplacing car keys or a wallet
c. Leaving a pot on the stove that boils...
443 Exam 2 Questions with Complete
Solutions
The daughter of a patient with early familial Alzheimer's disease (AD) asks how AD is
different from forgetfulness. You describe early warning signs of AD, including
a. Forgetting a colleague's name at a party
b. Repeatedly misplacing car keys or a wallet
c. Leaving a pot on the stove that boils dry and burns
d. Having no memory of preparing a meal and forgetting to serve or eat it - Answer-d.
Having no memory of preparing a meal and forgetting to serve or eat it
Frequent forgetfulness or unexplainable confusion at home or in the workplace may
signal that something is wrong. This type of memory loss goes beyond forgetting an
assignment, a colleague's name, a deadline, or a phone number. Difficulty performing
familiar tasks: It is not abnormal for most people to become distracted and to forget
something (e.g., leave something on the stove too long). People with Alzheimer's
disease (AD) may cook a meal but then forget not only to serve it but also that they
made it. Misplacing things: For many individuals, temporarily misplacing keys, purses,
or wallets is a normal albeit frustrating event. Persons with AD may put items in
inappropriate places (e.g., eating utensils in clothing drawers) but have no memory of
how they got there.
•Which intervention will the nurse include in the plan of care for a patient with moderate
dementia who had a fractured hip repair 2 days ago?
1.Provide complete personal hygiene care for the patient.
2.Remind the patient frequently about being in the hospital.
3.Reposition the patient frequently to avoid skin breakdown.
4.Place suction at the bedside to decrease the risk for aspiration. - Answer-2.Remind
the patient frequently about being in the hospital.
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.
D.B. is admitted to a long-term care facility. He has a nursing diagnosis of impaired
memory related to effects of dementia. An appropriate nursing intervention for him is to
a. let him know what behavior is socially appropriate.
b. assist him with all self-care to maintain self-esteem.
c. maintain familiar routines of sleep, meals, drug administration, and activities.
d. promote orientation at every encounter with the patient by asking the day, time, and
place. - Answer-c. maintain familiar routines of sleep, meals, drug administration, and
activities.
Rationale: The nurse should maintain familiar routines by identifying usual patterns of
behavior for activities such as sleep, medication use, elimination, food intake, and self-
care.
, Which action will help the nurse determine whether a new patient's confusion is caused
by dementia or delirium?
1.Ask about a family history of dementia.
2.Administer the Mini-Mental Status Exam.
3.Use the Confusion Assessment Method tool.
4.Obtain a list of the patient's usual medications. - Answer-3.Use the Confusion
Assessment Method tool.
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.
What does CIWA assess? - Answer-Nausea & Vomiting
Tactile Disturbances
Tremor
Auditory Disturbances
Paroxysmal Sweats
Visual Disturbances
Anxiety
Headache, fullness in head
Agitation
Orientation & Clouding of Sensorium
Over 20 = strong risk for DT
1. Pain is best described as
a. a creation of a person's imagination.
b. an unpleasant, subjective experience.
c. a maladaptive response to a stimulus.
d. a neurologic event resulting from activation of nociceptors. - Answer-b. an
unpleasant, subjective experience.
1. When admitting a patient, the nurse must assess the patient for substance use based
on the knowledge that long-term use of addictive substances leads to
a. the development of coexisting psychiatric illnesses.
b. a higher risk for complications from underlying health problems.
c. potentiation of effects of similar drugs taken when the individual is drug free.
d. increased availability of dopamine, resulting in decreased sleep requirements. -
Answer-b. a higher risk for complications from underlying health problems.
2. The nurse would suspect cocaine toxicity in the patient who is experiencing
a. agitation, dysrhythmias, and seizures.
b. blurred vision, restlessness, and irritability.
c. diarrhea, nausea and vomiting, and confusion.
d. slow, shallow respirations; bradycardia; and hypotension. - Answer-a. agitation,
dysrhythmias, and seizures.
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