A geriatric nurse is teaching the client’s family about the possible cause of delirium. Which statement by the nurse is most accurate?
- “Taking multiple medications may lead to adverse interactions or toxicity.”
- “Age-related cognitive changes may lead to alterations in mental status.”
- “Lack of rigorous exercise may lead to decreased cerebral blood flow.”
- “Decreased social interaction may lead to profound isolation and psychosis.”
Rationale: The nurse should identify that taking multiple medications that may lead to adverse reactions or toxicity is a risk factor for the development of delirium in older adults. Symptoms of delirium include difficulty sustaining and shifting attention. The client with delirium is disoriented to time and place and may also have impaired memory.
A husband has agreed to admit his spouse, diagnosed with Alzheimer’s disease (AD), to a long-term care facility. He is expressing feelings of guilt and symptoms of depression. Which appropriate nursing diagnosis and subsequent intervention would the nurse document?
- Dysfunctional grieving; AD support group
- Altered thought process; AD support group
- Major depressive episode; psychiatric referral
- Caregiver role strain; psychiatric referral
Rationale: The most appropriate nursing diagnosis and intervention for the husband is dysfunctional grieving; AD support group. Clients with AD are often at risk for trauma and have significant self-care deficits that require more care than a spouse may be able to provide.
A client diagnosed with vascular neurocognitive disorder (NCD) is discharged to home under the care of his wife. Which information should cause the nurse to question the client’s safety?
- His wife works from home in telecommunication.
- The client has worked the nightshift his entire career.
- His wife has minimal family support.
- The client smokes one pack of cigarettes per day.
Rationale: The nurse should question the client’s safety at home if the client smokes cigarettes. Vascular NCD is a clinical syndrome of NCD due to significant cerebrovascular disease. The cause of vascular NCD is related to an interruption of blood flow to the brain. Hypertension is a significant factor in the etiology.
A client diagnosed with AD can no longer ambulate, does not recognize family members, and communicates with agitated behaviors and incoherent verbalizations. The nurse recognizes these symptoms as indicative of which stage of the illness?
- Stage 4: Mild-to-Moderate Cognitive Decline
- Stage 5. Moderate Cognitive Decline
- Stage 6. Moderate-to-Severe Cognitive Decline
- Stage 7. Severe Cognitive Decline
Rationale: The nurse should recognize that a client exhibiting these symptoms is in the severe cognitive decline, seventh stage, of AD.
A client is diagnosed in stage seven of AD. To address the client’s symptoms, which nursing intervention should take priority?
- Improve cognitive status by encouraging involvement in social activities.
- Decrease social isolation by providing group therapies.
- Promote dignity by providing comfort, safety, and self-care measures.
- Facilitate communication by providing assistive devices.
Rationale: The most appropriate intervention in the seventh stage of AD is to promote the client’s dignity by providing comfort, safety, and self-care measures. Stage is characterized by severe cognitive decline in which the client is unable to recognize family members and is most commonly bedfast and aphasic.
Which is the reason for the proliferation of the diagnosis of NCDs?
- Increased numbers of neurotransmitters has been implicated in the proliferation of NCD.
- Similar symptoms of NCD and depression lead to misdiagnoses, increasing numbers of NCD.
- Societal stress contributes to the increase in this diagnosis.
- More people now survive into the high-risk period for neurocognitive disorders.
Rationale: The proliferation of NCD has occurred because more people now survive into the high-risk period for neurocognitive disorder, which is middle age and beyond..
Cognitive Level: Application
Integrated Process: Assessment
A client diagnosed recently with AD is prescribed donepezil (Aricept). The client’s spouse inquires, “How does this work? Will this cure him?” Which is the appropriate nursing response?
- “This medication delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the disease.”
- “This medication encourages production of acetylcholine, a chemical in the brain necessary for memory processes. It delays the progression of the disease.”
- “This medication delays the destruction of dopamine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the disease.”
- “This medication encourages production of dopamine, a chemical in the brain necessary for memory processes. It delays the progression of the disease.”
Rationale: The most appropriate response by the nurse is to explain that donepezil delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the AD. Some side effects include dizziness, headache, gastrointestinal upset, and elevated transaminase.
Which symptom should a nurse identify that differentiates clients diagnosed with NCDs from clients diagnosed with mood disorders?
- Altered sleep
- Altered concentration
- Impaired memory
- Impaired psychomotor activity
Rationale: The nurse should identify that impaired memory is a symptom that occurs in NCD and not in mood disorders. Neurocognitive disorder is classified in the DSM-5 as either mild or major, with the distinction primarily being one of severity of symptomatology.
A client diagnosed with AD exhibits progressive memory loss, diminished cognitive functioning, and verbal aggression upon experiencing frustration. Which nursing intervention is most appropriate?
- Organize a group activity to present reality.
- Minimize environmental lighting.
- Schedule structured daily routines.
- Explain the consequences for aggressive behaviors.
Rationale: The most appropriate nursing intervention for this client is to schedule structured daily routines. A structured routine will reduce frustration and thereby reduce verbal aggression.
After one week of continuous mental confusion, an older African American client is admitted with a preliminary diagnosis of AD. What should cause the nurse to question this diagnosis?
- AD does not typically occur in African American clients.
- The symptoms presented are more indicative of Parkinsonism.
- AD does not develop suddenly.
- There has been no T3- or T4-level evaluation ordered.
Rationale: The nurse should recognize that AD does not develop suddenly and should question this diagnosis. The onset of AD symptoms is slow and insidious. The disease is generally progressive and deteriorating.
A client diagnosed with AD has impairments of memory and judgment and is incapable of performing activities of daily living. Which nursing intervention should take priority?
- Present evidence of objective reality to improve cognition.
- Design a bulletin board to represent the current season.
- Label the client’s room with name and number.
- Assist with bathing and toileting.
Rationale: The priority nursing intervention for this client is to assist with bathing and toileting. A client who is incapable of performing activities of daily living requires assistance in these areas to ensure health and safety.
A client diagnosed with major NCD is exhibiting behavioral problems on a daily basis. At change of shift, the client’s behavior escalates from pacing to screaming and flailing. Which action should be a nursing priority?
- Consult the psychologist regarding behavior-modification techniques.
- Medicate the client with prn antianxiety medications.
- Assess environmental triggers and potential unmet needs.
- Anticipate the behavior and restrain when pacing begins.
Rationale: The priority nursing action is to first medicate the client to avoid injury to self or others. It is important to assess environmental triggers and potential unmet needs in order to address these problems in the future, but interventions to ensure safety must take priority. Because of the cognitive decline experienced in clients diagnosed with this disorder, communication skills and orientation may limit assessment and teaching interventions.
A client with a history of cerebrovascular accident (CVA) is brought to an emergency department experiencing memory problems, confusion, and disorientation. Based on this client’s assessment data, which diagnosis would the nurse expect the physician to assign?
- Delirium due to adverse effects of cardiac medications
- Vascular neurocognitive disorder
- Altered thought processes
- Alzheimer’s disease
Rationale: The nurse should expect that the client will be diagnosed with vascular NCD, which is caused by significant cerebrovascular disease. Vascular NCD often has an abrupt onset. Progression of this disease often occurs in a fluctuating pattern.
An older client has recently moved to a nursing home. The client has trouble concentrating and socially isolates. A physician believes the client would benefit from medication therapy. Which medication should the nurse expect the physician to prescribe?
- Haloperidol (Haldol)
- Donepezil (Aricept)
- Diazepam (Valium)
- Sertraline (Zoloft)
Rationale: The nurse should expect the physician to prescribe sertraline to improve the client’s social functioning and concentration levels. Sertraline is an selective serotonin reuptake inhibitor (SSRI) antidepressant. Depression is the most common mental illness in older adults and is often misdiagnosed as a neurocognitive disorder.
A client diagnosed with NCD is disoriented and ataxic and wanders. Which is the priority nursing diagnosis?
- Disturbed thought processes
- Self-care deficit
- Risk for injury
- Altered health-care maintenance
Rationale: The priority nursing diagnosis for this client is risk for injury. The client who is ataxic suffers from motor coordination deficits and is at an increased risk for falls. Clients that wander are at a higher risk for injury.
Which statement accurately differentiates mild NCD from major NCD?
- Major NCD involves disorientation that develops suddenly, whereas mild NCD develops more slowly.
- Major NCD involves impairment of abstract thinking and judgment, whereas mild NCD does not.
- Major NCD criteria requires substantial cognitive decline from a previous level of performance, and mild NCD requires modest decline.
- Major NCD criteria requires decline from a previous level of performance in three of the listed domains, and mild NCD requires only one.
Rationale: The progression of the disorder is not a criterion for determining the severity of an NCD. Abstract thinking and judgment can be affected in both mild NCD and major NCD. Major NCD criteria requires substantial cognitive decline, and mild NCD requires modest decline. Both major and mild NCD classifications require decline from a previous level of performance in only one of the listed domains.
Which statement accurately differentiates NCD from pseudodementia (depression)?
- NCD has a rapid onset, whereas pseudodementia does not.
- NCD symptoms include disorientation to time and place, and pseudodementia does not.
- NCD symptoms improve as the day progresses, but symptoms of pseudodementia worsen.
- NCD causes decreased appetite, whereas pseudodementia does not.
Rationale: NCD has a slow progression of symptoms, whereas pseudodementia has a rapid progression of symptoms. NCD symptoms include disorientation to time and place, and pseudodementia does not. NCD symptoms’ severity worsens as the day progresses, whereas in pseudodementia, symptoms improve as the day progresses. In NCD the appetite remains unchanged. whereas in pseudodementia, the appetite diminishes.
Which of the following conditions have been known to precipitate delirium in some individuals? (Select all that apply.)
- Febrile illness
- Migraine headaches
- Herniated brain stem
- Temporomandibular joint syndrome
ANS: 1, 2, 3
Rationale: Delirium most commonly occurs in individuals with serious medical, surgical, or neurological conditions. Some examples of conditions that have been known to precipitate delirium in some individuals include the following: systemic infections; febrile illness; metabolic disorders, such as hypoxia, hypercarbia, or hypoglycemia; hepatic encephalopathy; head trauma; seizures; migraine headaches; brain abscess; stroke; postoperative states; and electrolyte imbalance. A herniated brain stem would most likely result in death, not delirium. Temporomandibular joint syndrome is marked by limited movement of the joint during chewing, not delirium.
Which of the following medications that have been known to precipitate delirium? (Select all that apply.)
- Antineoplastic agents
- H2-receptor antagonists
- Lipid-lowering agents
ANS: 1, 2, 3, 4
Rationale: Medications that have been known to precipitate delirium include anticholinergics, antihypertensives, corticosteroids, anticonvulsants, cardiac glycosides, analgesics, anesthetics, antineoplastic agents, antiparkinson drugs, H2-receptor antagonists (e.g., cimetidine), and others. There have been no reports of delirium ascribed to the use of lipid-lowering agents.