ATI LPN
Test Bank for Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care, 4e 4th Edition
Chapter 18 Questions
Question 1 of 5
An older adult takes digoxin and hydrochlorothiazide daily, as well as lorazepam as needed for anxiety. Over 2 days, this adult developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of which adverse reaction to the medication therapy?
Correct Answer: A
Rationale: Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer's disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems.
Question 2 of 5
A patient experiencing fluctuating levels of awareness, confusion, and disturbed orientation shouts, 'Bugs are crawling on my legs! Get them off!' Which problem is the patient experiencing?
Correct Answer: C
Rationale: The patient feels bugs crawling on both legs, although no sensory stimulus is actually present. This description coincides with the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium.
Question 3 of 5
A patient experiencing fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, 'Someone get these bugs off me.' What is the nurse's best response?
Correct Answer: D
Rationale: When hallucinations are present, the nurse should acknowledge the patient's feelings and state the nurse's perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patient's perception without offering help does not emotionally support the patient. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions.
Question 4 of 5
What is the priority nursing diagnosis for a patient experiencing fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?
Correct Answer: B
Rationale: The physical safety of the patient is the highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful; when the patient exercises poor judgment; and when the patient's sensorium is clouded. The other diagnoses may be concerns but are lower priorities.
Question 5 of 5
What is the priority nursing intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations?
Correct Answer: C
Rationale: Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient remains safe and free from injury. Physical contact during care cannot be avoided. Restraint is a last resort, and sensory stimulation should be reduced.