Question 1 of 6
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Which intervention would the nurse use to help a patient with Alzheimer disease who is restless and agitated?
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- Redirect the patient’s focusReassurance involves communicating protection from danger, harm, or embarrassment. Redirecting is changing the patient’s focus to perform other nonthreatening activities.
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- Call the health care providerCalling the health care provider is not necessary unless there is a need to report unusual symptoms or to obtain a prescription for medication, restraints, or diagnostic testing.
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- Ask the patient why he is so agitatedThe nurse would not ask an agitated or confused patient to explain behavior.
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- Tell the patient to calm down or be isolatedThreatening the patient (“calm down or else”) is likely to aggravate the behavior, and the patient lacks the capacity to link actions to consequences.
Question 2 of 6
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Which type of environment would be provided for a hospitalized patient who has delirium?
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- Stimulating environmentDelirium is acute, short-term disorientation and confusion, and the priority is patient safety.
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- Quiet environmentA quiet environment would help decrease the patient’s agitation.
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- Familiar environmentProviding a familiar environment may not be possible because of care requirements and limitations of the hospital facility.
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- Structured environmentSetting limits and explaining rules are used to provide structure, but these measures are ineffective and counterproductive when a patient is delirious.
Question 3 of 6
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Which patient problem would the nurse investigate first for a patient with moderate Alzheimer disease (AD) who demonstrates unusually increased vocalization?
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- Acute confusion due to infection-induced deliriumThe nurse would conduct additional assessment to determine whether infection is present.
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- Sleep disturbances due to age-related changesThe nurse would conduct additional assessment to determine whether sleep patterns would be reviewed.
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- Chronic confusion due to progressive memory lossThe nurse would conduct additional assessment, and baseline confusion would be compared to current mental status.
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- Pain with difficulty expressing physical complaintsPatients with AD may have difficulty expressing physical complaints, including pain. First, the nurse would observe for other signs of pain, such as increased withdrawal, protecting an area, repeatedly touching or rubbing an area, and changes in function. Pain should be recognized and treated promptly, and the patient’s response should be monitored.
Question 4 of 6
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Which instruction would the nurse give to a group of caregivers about caring for a patient in the severe stage of Alzheimer disease (AD)?
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- “Avoid correcting misstatements.”Tactfully handling misstatements is an appropriate intervention in the earlier stages, but by the late stages the patient’s abilities to talk are highly impaired.
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- “Advise the patient to stop driving.”Discontinuing activities that require judgment is an appropriate intervention in the earlier stages, but by the late stages the patient’s abilities to perform any activities are highly impaired.
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- “Continue communication through talking and touching.”In the severe stage of AD, the patient has profound loss of memory and cognition and may be confined to bed. Communication would be done through talking and touching.
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- “Register with MedicAlert and Alzheimer’s Association Safe Return.”Registering with safety agencies is an appropriate intervention in the earlier stages, but by the late stages the patient’s abilities to wander are highly impaired.
Question 5 of 6
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Which instruction would the nurse give staff when educating them on reality orientation?
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- “It is most beneficial for patients with global amnesia.”Patients experiencing global amnesia would not benefit from repeated verbal reality orientation as they are unable to retain the information.
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- “It is OK to become frustrated when the patient struggles to remember.”Under no circumstances would you ever chastise or become frustrated when a patient is unable to remember. This is considered both inappropriate and nontherapeutic.
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- “Group sessions often provide too much stimulation.”Group sessions are useful to help orient patients. The sessions can focus on person, place, time, and holiday and also provide an opportunity for social interactions.
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- “Clocks with large numbers can be helpful.”Clocks with large numbers help orient the patient to the correct time.
Question 6 of 6
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Which are appropriate guidelines for the safe use of restraints? Select all that apply. One, some, or all responses may be correct.
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- Check the area distal to the restraint every shift.The area distal to the restraint would be checked every 2 hours for circulation and function.
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- Restraints are never used as punishment.Restraints would never be used to punish or control the patient.
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- Tie restraints with quick-release knots.Tying restraints with quick-release knots is appropriate to ensure the restraints can be removed quickly as needed.
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- The nurse can order restraints.You need a health care provider’s order to initiate restraints.
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- Ensure the hands are uncovered at all times.It is appropriate to use hand mitts for patients who are receiving intravenous therapy or who have catheters or nasogastric tubes.
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- Obtain informed consent before using restraints.You need to obtain informed consent from the patient or the patient’s family before using restraints.
