Chapter 13

25問 • 1年前

問題一覧

Which descriptions are related to delirium? Select all that apply.

Short-term confusional state, Acute confusional state, Often reversible confusion, Characterized by disturbances in attention, thinking, and perception

Which descriptions are related to dementia? Select all that apply.

Characterized by impaired intellectual function, Flat or indifferent affect

______Speech may be slurred and disjointed with endless repetitions

Delirium

______Engaging in conversation may be difficult

Delirium

______Generally considered irreversible

Dementia

______Significant cognitive decline from a previous level of performance in one or more areas of cognitive domain

Dementia

______Difficulty paying attention; easily distracted

Delirium

The use of physical restraints should be avoided with patients with delirium because restraints tend to:

increase anxiety.

When a patient with dementia resists activities such as bathing or dressing, the nurse should:

avoid confrontations.

Patients with dementia should be offered:

finger foods high in protein and carbohydrates.

When the nurse is taking care of patients with dementia, it is helpful to remember that they usually:

forget things quickly.

Which approach may agitate patients with dementia?

Reality orientation

When caring for a patient with delirium, the nurse should:

provide frequent orientation to surroundings.

Which medications may cause delirium? Select all that apply.

Sedatives, Opioids, Antianxiety agents, Antidepressants

Which are general medical illnesses or conditions that may result in dementia? Select all that apply.

Alzheimer disease, HIV infection, Parkinson disease

Which are underlying medical illnesses or conditions that may cause delirium? Select all that apply.

Dehydration, Overmedication, Infection, Fluid and electrolyte imbalance

Which are medications that most often cause confusion in older adults? Select all that apply.

Anticholinergic drugs, H2-receptor blockers, Nonsteroidal antiinflammatory drugs (NSAIDs)

What do the majority of people fear most about aging?

Loss of independence

The nurse in a long-term care facility is assisting with the admission of a patient with confusion. What is the first step in collecting data about a confused person?

Observe the behavior of the patient.

When the nurse is caring for a delirious patient who is experiencing hallucinations, the best response of the nurse would be:

“You are sick in the hospital, and what you are seeing is part of the illness.”

A female patient with dementia starts to become very restless and agitated. Which is an effective nursing intervention for this patient?

Divert her attention and gently guide her to a new activity.

A patient with dementia tells the nurse that he is afraid of bathtubs. The nurse’s best response is to:

arrange another way to give personal care.

Which concepts should be used as a basis for providing care for patients with dementia? Select all that apply.

Patients usually forget things relatively quickly., Patients are usually unable to learn new things., Break down tasks into individual steps to be done one at a time.

A patient with delirium is having trouble falling asleep. Which is the most appropriate nursing intervention to help this patient fall asleep?

A backrub, a glass of warm milk, and soothing conversation

Health History: 81-year-old man admitted for hip replacement surgery 2 days ago. Prior to admission client lived alone and cared for himself. Client previously active, alert, and independent. However, since his surgery, he has been combative with the nurses. Client may be suffering from delirium related to the anesthesia from surgery, should resolve within a few days. 1. Based on the client information provided, what would be the nurse’s priority nursing intervention?

Provide safety and reduce anxiety.

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