ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 62 Questions
Question 1 of 5
The nurse is caring for a long-term care patient with moderate dementia who develops increased restlessness and agitation. Which of the following actions should the nurse implement initially?
Correct Answer: C
Rationale: Increased motor activity in a patient with dementia is frequently the patient's only way of responding to factors like pain, so the nurse's 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 a nursing assistant to stay with the patient also may be necessary, but any physical changes that may be causing the agitation should be addressed first.
Question 2 of 5
The nurse is assessing a patient who is diagnosed with middle (moderate) dementia as a result of multiple strokes. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: Loss of both recent and long-term memory is characteristic of middle dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient's ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia.
Question 3 of 5
During the morning change-of-shift report at the long-term care facility, the nurse learns that the patient with dementia has had sundowning. Which of the following nursing actions should the nurse take while caring for the patient?
Correct Answer: C
Rationale: The most likely cause of sundowning is a disruption in circadian rhythms and keeping the patient active and in daylight will help to re-establish 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 memory difficulties.
Question 4 of 5
To determine whether a new patient's confusion is caused by dementia or delirium, which of the following actions should the nurse take?
Correct Answer: D
Rationale: 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.
Question 5 of 5
The nurse is assessing a patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility and the nurse learns that the patient has had several episodes of wandering from home. Which of the following nursing actions should the nurse include in the plan of care?
Correct Answer: A
Rationale: Patients at risk for problems with safety require close supervision. Placing the patient near the nurse's station will allow nursing staff to observe the patient more closely. The use of 'why' questions is frustrating for patients with AD because they are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patient's short-term memory loss, reorientation will not help prevent wandering behaviour. Because the patient had wandering behaviour at home, familiar objects will not prevent wandering.