Chapter 23: Neurocognitive Disorders |Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 8th Edition

MULTIPLE CHOICE 1. An older adult patient takes multiple medications daily. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of a. delirium. b. dementia. c. amnestic syndrome. d. Alzheimer‘s disease. ANS: A Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer‘s disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 23-3, 4 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 2. A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, ―Bugs are crawling on my legs. Get them off!‖ Which problem is the patient experiencing? a. Aphasia b. Dystonia c. Tactile hallucinations d. Mnemonic disturbance ANS: C The patient feels bugs crawling on both legs, even though no sensory stimulus is actually present. This description meets the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 23-6, 7 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 3. A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, ―Someone get these bugs off me.‖ What is the nurse‘s best response? a. No bugs are on your legs. You are having hallucinations.‖ b. I will have someone stay here and brush off the bugs for you.‖ c. Try to relax. The crawling sensation will go away sooner if you can relax.‖ d. I don‘t see any bugs, but I can tell you are frightened. I will stay with you.‖ ANS: D When hallucinations are present, the nurse should acknowledge the patient‘s feelings and state the nurse‘s perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patient‘s perception without offering help does not support the patient emotionally. Telling the patient to relax makes the patient responsible for self- soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 23-3, 6, 7, 61 (Box 23-2) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 4. What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks c. Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations