Med Surg TB Chapter 59 Flashcards


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1

A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia?

A) The patient was oriented and alert when admitted.

B) The patients speech is fragmented and incoherent.

C) The patient is oriented to person but disoriented to place and time.

D) The patient has a history of increasing confusion over several years.

Answer: A

2

Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had an appendectomy 2 days ago?

A) Provide complete personal hygiene care for the patient.

B) Remind the patient frequently about being in the hospital.

C) Reposition the patient frequently to avoid skin breakdown.

D) Place suction at the bedside to decrease the risk for aspiration.

Answer: B

3

When administering a mental status examination to a patient with delirium, the nurse should

A) wait until the patient is well-rested.

B) administer an anxiolytic medication.

C) choose a place without distracting stimuli.

D) reorient the patient during the examination.

Answer: C

4

The nurse is concerned about a postoperative patients risk for injury during an episode of delirium. The most appropriate action by the nurse is to

A) secure the patient in bed using a soft chest restraint.

B) ask the health care provider to order an antipsychotic drug.

C) instruct family members to remain with the patient and prevent injury.

D) assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation.

Answer: D

5

A 56-year-old patient in the outpatient clinic is diagnosed with mild cognitive impairment (MCI). Which action will the nurse include in the plan of care?

A) Suggest a move into an assisted living facility.

B) Schedule the patient for more frequent appointments.

C) Ask family members to supervise the patients daily activities.

D) Discuss the preventive use of acetylcholinesterase medications.

Answer: B

6

The nurse is administering a mental status examination to a 48-year-old patient who has hypertension. The nurse suspects depression when the patient responds to the nurses questions with

A) Is that right?

B) I dont know.

C) Wait, let me think about that.

D) Who are those people over there?

Answer: B

7

A 68-year-old patient is diagnosed with moderate dementia after multiple strokes. During assessment of the patient, the nurse would expect to find

A) excessive nighttime sleepiness.

B) difficulty eating and swallowing.

C) loss of recent and long-term memory.

D) fluctuating ability to perform simple tasks

Answer: C

8

Which action will help the nurse determine whether a new patients confusion is caused by dementia or delirium?

A) Administer the Mini-Mental Status Exam.

B) Use the Confusion Assessment Method tool.

C) Determine whether there is a family history of dementia.

D) Obtain a list of the medications that the patient usually takes

Answer: B

9

A 72-year-old female patient is brought to the clinic by the patients spouse, who reports that she is unable to solve common problems around the house. To obtain information about the patients current mental status, which question should the nurse ask the patient?

A) Are you sad?

B)How is your self-image?

C) Where were you were born?

D) What did you eat for breakfast?

Answer: D

10

A patient is being evaluated for Alzheimers disease (AD). The nurse explains to the patients adult children that

A) the most important risk factor for AD is a family history of the disorder.

B) new drugs have been shown to reverse AD dramatically in some patients.

C) a diagnosis of AD is made only after other causes of dementia are ruled out.

D) the presence of brain atrophy detected by magnetic resonance imaging (MRI) will confirm the diagnosis of AD.

Answer: C

11

Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia?

A) Setting the medications up monthly in a medication box

B) Having the patients family member administer the medication

C) Posting reminders to take the medications in the patients house

D) Calling the patient weekly with a reminder to take the medication

Answer: B

12

A patient who has severe Alzheimers disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care?

A) Encourage the patient to discuss events from the past.

B) Maintain a consistent daily routine for the patients care.

C) Reorient the patient to the date and time every 2 to 3 hours.

D) Provide the patient with current newspapers and magazines.

Answer: B

13

A 71-year-old patient with Alzheimers disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care?

A) Reorient the patient several times daily.

B) Have the family bring in familiar items.

C) Place the patient in a room close to the nurses station.

D) Ask the patient why the wandering episodes have occurred.

Answer: C

14

The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which action should the nurse take?

A) Keep blinds open during the daytime hours.

B) Provide hourly orientation to time and place.

C) Have the patient take a brief mid-morning nap.

D Move the patient to a quieter room late in the afternoon.

Answer: A

15

The nurses initial action for a patient with moderate dementia who develops increased restlessness and agitation should be to

A) reorient the patient to time, place, and person.

B) administer a PRN dose of lorazepam (Ativan).

C) assess for factors that might be causing discomfort.

D) assign unlicensed assistive personnel (UAP) to stay in the patients room.

Answer: C

16

When administering the Mini-Cog exam to a patient with possible Alzheimers disease, which action will the nurse take?

A) Check the patients orientation to time and date.

B) Obtain a list of the patients prescribed medications.

C) Ask the person to use a clock drawing to indicate a specific time.

D) Determine the patients ability to recognize a common object such as a pen.

Answer: C

17

Which hospitalized patient will the nurse assign to the room closest to the nurses station?

A) Patient with Alzheimers disease who has long-term memory deficit

B) Patient with vascular dementia who takes medications for depression

C) Patient with new-onset confusion, restlessness, and irritability after surgery

D) Patient with dementia who has an abnormal Mini-Mental State Examination

Answer: C

18

After change-of-shift report on the Alzheimers disease/dementia unit, which patient will the nurse assess first?

A) Patient who has not had a bowel movement for 5 days

B) Patient who has a stage II pressure ulcer on the coccyx

C) Patient who is refusing to take the prescribed medications

D) Patient who developed a new cough after eating breakfast

Answer: D