ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 62 Questions
Question 1 of 5
The nurse is caring for a patient who was hospitalized with pneumonia 2 days ago, now displaying disorientation and confusion. Which of the following information indicates that the patient is experiencing delirium rather than dementia?
Correct Answer: A
Rationale: 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.
Question 2 of 5
The nurse is developing a plan of care for a hospitalized patient with moderate dementia. Which of the following interventions should the nurse include?
Correct Answer: B
Rationale: 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.
Question 3 of 5
The nurse is caring for a patient with dementia with Lewy bodies (DLB). Which of the following complications is the patient most at risk for developing related to DLB?
Correct Answer: B
Rationale: Pneumonia is a common complication in patients with DLB due to impaired mobility and swallowing difficulties, which increase aspiration risk. They are not at an increased risk of stroke, myocardial infarction, or urinary tract infection specifically related to DLB.
Question 4 of 5
Which of the following actions is most appropriate for the nurse to implement to protect a patient from injury during an episode of delirium?
Correct Answer: D
Rationale: The priority goal is to protect the patient from harm, and a staff member will be most experienced in providing safe care. 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 multiple adverse effects. Restraints are sometimes used but tend to increase agitation and disorientation.
Question 5 of 5
Which of the following actions should the nurse in the outpatient clinic include in the plan of care for a patient with mild cognitive impairment (MCI)?
Correct Answer: B
Rationale: Ongoing monitoring is recommended for patients with MCI. If mild cognitive impairment (MCI) is diagnosed, annual monitoring of symptoms and functioning is recommended. 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.