Chapter 017

Varcarolis: Foundations of Psychiatric Mental Health Nursing, 6th Edition
Chapter 17: Cognitive Disorders

Test Bank
MULTIPLE CHOICE
1.
a.
b.
c.
d.
A widow, aged 72 years, lives alone and is visited weekly by her son. She takes digoxin,
hydrochlorothiazide, and an antihypertensive drug. She also has a prescription for
diazepam (Valium) as needed for moderate to severe anxiety. When the son visited today,
he found his mother confused. Her speech was thick and slurred and she had an unsteady
gait. She was taken to the emergency department, and hospital admission followed. The
nurse assessed the patient as having several cognitive problems, including memory and
attention deficits and fluctuating levels of orientation. The nurse confirms that the
patients symptoms developed over a 2-day period. The patients symptoms are most
characteristic of:
delirium.
dementia.
amnestic syndrome.
Alzheimers disease.
ANS: A
Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded
and/or fluctuating consciousness, perceptual disturbances, and disturbed memory and
orientation. The onset of dementia or Alzheimers disease, a type of dementia, is more
insidious. Amnestic syndrome involves memory impairment without other cognitive
problems.
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
2.
a.
b.
c.
d.
REF: Text Pages: 375, 381

MSC: Client Needs: Physiological Integrity
A patient with fluctuating levels of awareness, confusion, and disorientation shouts, The
bugs, they are crawling on my legs! Get them off me! The nurses inspections show that
no insects or other possible causes of the patients perceptions are visible. The nurse can
best assess this presentation as:
perseveration.
hypermetamorphosis.
tactile hallucinations.
tactile illusions.
ANS: C
The patient feels bugs crawling on her legs, even though no sensory stimulus is actually
present. A false sensory perception is called a hallucination, and when the sense involved is
touch (the sensation of bugs crawling on her body) the experience is called tactile
hallucinations. These are often a part of the symptom constellation of delirium. Perseveration
is the purposeless repetition of a particular theme, phrase or behavior. Hypermetamorphosis is
a behavior wherein the patient is drawn to touching everything in his/her environment (as if
sampling them by touch). An illusion is a misperception of a genuine stimulus (e.g., a patient
Elsevier items and derived items 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Test Bank
17-2
in a dimly lit room mistakes a coat on a coat rack for a person standing in the corner.) In this
scenario, there is no evidence of a basis in reality for the patients perception.
DIF: Cognitive Level: Application
3.
a.
b.
c.
d.
REF: Text Pages: 373, 381, 384

A patient in a dimly lit room demonstrates fluctuating levels of consciousness, disturbed

orientation, and perceptual alterations and begs the nurse to get the bugs off her. Which
nursing response would be most therapeutic?
There are no bugs on your legs. Your imagination is playing tricks on you.
Try to relax. The crawling sensation will go away sooner if you can relax.
Dont worry, I will have someone stay here and brush away the bugs for you.
I dont see bugs, but Ill stay with you and brighten the lights so we can be sure.
ANS: D
Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity
for reinforcing reality, and provides a measure of physical safety. Brightening the lights allows
the patient to reassess reality and enables her to question whether her experience was real or
mistaken. Also, if she can see that no insects are present despite her sensations, she will likely
experience a reduction in anxiety. When hallucinations are present, the nurse should
acknowledge the patient's feelings and state the nurse's perception of reality but not refute the
patients experience. Your imagination is playing tricks on you does not meet these
guidelines for intervention and does not support the patient emotionally. Directing the patient
to relax sets up an unrealistic expectation, given what she perceives is happening. Indicating
that someone will brush the bugs away suggests that the patients perceptions are based in
reality and reinforces the hallucinatory experience.
REF: Text Pages: 387-389
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
4.
What should the priority nursing diagnosis be for a patient with fluctuating levels of
consciousness, disorientation, and visual and tactile hallucinations?
a. Self-care deficit
b. Risk for injury
c. Disturbed thought processes
d. Fear
ANS: B
The physical safety of the patient is the highest priority, and among the diagnoses given here
Risk for injury is most directly related to the patients physical safety. Fluctuating
consciousness could lead to falls, or disorientation could lead to injuries during activities of
daily living. Hallucinations can induce fear that could lead to dangerous defensive behavior.
The other diagnoses, although valid, do not relate to safety and are of lower priority.
TOP: Nursing Process: Nursing Diagnosis
Test Bank
5.
a.
b.
c.
d.
17-3
What environmental conditions should the nurse arrange for a patient with delirium and
altered perceptions of her environment?
Provide a quiet, well-lit room without glare or shadows.
Have the patient sit by the nurses desk while awake.
Reduce room lighting to minimize overstimulation.
Keep a radio on continuously to reduce isolation.
ANS: A
A quiet, well-lit, shadow-free room offers an environment that minimizes opportunities to
misperceive reality or become overwhelmed by stimuli. Having the patient sit at the nurses
station facilitates observation but does not necessarily reduce misperceptions. Reducing room
lighting makes objects less easily seen and more likely to be misinterpreted or misperceived.
Continuous exposure to a radio could result in stimulus overload, aggravating the patients
cognitive impairment.
6.
a.
b.
c.
d.
A patient is referred to the visiting nurse agency due to cognitive impairment. Which
functional problems is this patient most likely to exhibit?
Inability to bathe and dress independently
Wandering in and away from his home
Lability of moods, from sociable to irritable
Becomes frustrated easily
ANS: A
Inability to bathe and dress suggests apraxia, the loss of ability to perform purposeful
movements even though motor or sensory function are intact. For example, the patient may
have impaired executive function and no longer be able to organize the steps and supplies
necessary to complete activities of daily living. The other symptoms are less directly
attributable to loss of cognitive ability.

7.
A man, aged 84 years, was stopped for going through a red light in a small town where
he has lived all his life. He told the officer, It wasnt there yesterday. He was unable to tell
the officer his address and demonstrated labile mood, seeming pleasant one minute and angry
the next. The officer took the man home to discuss his condition with the family and found
that he lives with his wife, who is legally blind. She stated, Hes my eyes, and Im his mind.
She also related that her husband wanders around the neighborhood, sometimes taking tools
from peoples garages, saying they belong to him. She reluctantly agreed that he should go to
the emergency department for evaluation. He was diagnosed with Alzheimers disease. What
cardinal sign of Alzheimers disease does this patient demonstrate?
a. Aphasia
Test Bank
17-4
b. Apraxia
c. Agnosia
d. Amnesia
ANS: D
Of the cardinal signs of Alzheimers disease, the patient is presently demonstrating only
amnestic disturbance, or memory loss. Aphasia refers to the alterations in the understanding
or expression of language through speech. Apraxia involves an impaired ability to complete
tasks despite having intact sensory and motor abilities. Agnosia refers to the loss of ability to
recognize objects, sounds, and images.
DIF: Cognitive Level: Comprehension
8.
a.
b.
c.
d.
REF: Text Page: 381

MSC: Client Needs: Psychosocial Integrity
An elderly man drove from his home to a nearby convenience store and was unable to
remember how to get home. He was unable to tell a police officer his address and
demonstrated labile mood. The officer took the man and met the mans wife, who related
that her husband often wanders around the neighborhood, sometimes taking tools from
peoples garages. She reluctantly agreed that he should go to the emergency department
for evaluation. He was diagnosed with Alzheimers disease. On the basis of the patients
history, the nurse can make the assessment that the patients Alzheimers disease has
progressed to:
stage 1 (mild).
stage 2 (moderate).
stage 3 (moderate to severe).
stage 4 (late).
ANS: B
In stage 2, deterioration is evident. Memory loss may include the inability to remember
addresses or the date. Mood is labile. Activities such as driving may become hazardous, as
seen here, and increasing difficulty in performing ordinary tasks leads to frustration. Hygiene
may begin to deteriorate. Stage 1 is the mildest stage; amnestic changes are evident but
functioning is generally intact. Stage 3 finds the individual unable to identify familiar objects
or people, and needing direction for the simplest of tasks. In stage 4, the ability to talk and
walk are eventually lost and stupor evolves.
9.
As Alzheimers disease progresses to the late stage (stage 4), impairment of functioning is
pervasive. Which symptom does not usually appear until this final stage of the disorder?
a. Agnosia
b. Social withdrawal
c. Confabulation
d. Hypermetamorphosis
ANS: D
Test Bank
17-5
Hypermetamorphosis, the process of touching everything in ones environment as a way of

sensing or familiarizing oneself with those objects, occurs during the fourth stage of
Alzheimers disease. Agnosia appears by the third stage, confabulation usually during the
second stage, and social withdrawal starts in the first phase.
TOP: Nursing Process: Planning

10. A patient with stage 1 Alzheimers disease complains of low energy. She prefers to
remain at home rather than attend club meetings and church. Her husband has been doing
the grocery shopping because his wife cannot remember what to purchase and is unable
to find her way around the store unassisted. Which nursing diagnosis would be most
appropriate for this patient?
a. Risk for injury
b. Impaired memory
c. Self-care deficit
d. Caregiver role strain
ANS: B
Memory impairment is present but not sufficiently so to create risk of injury or impair selfcare. Although the husband assists her with selected complex tasks, the patient remains
sufficiently capable of basic activities of daily living that she does not need a caregiver.
11. A 70-year-old woman is beginning to notice mild memory impairment. She fears she is
developing Alzheimers disease and asks her granddaughter, a nurse, if this is the case.
What factors would the nurse and her grandmother use to distinguish normal age-related
memory impairment from a developing dementia?
a. Only dementias interfere with the ability to solve new problems.
b. Difficulty finding words occurs in dementia but not normal aging.
c. Normal changes of aging do not interfere with day-to-day functioning.
d. Dementia progresses much more rapidly than the changes of normal aging.
ANS: C
The normal memory changes associated with aging are not severe enough to interfere with
completion of activities of daily living. Normal aging changes can cause reduced problem
solving and difficulty with word finding, although to a milder degree than dementia. Although
both normal aging changes and dementia progress slowly, the changes develop somewhat
more rapidly, but not much more rapidly, in dementia.
REF: Text Page: 379

Test Bank
17-6
12. Which assessment data suggests a person who appears to have dementia instead has
depression and pseudodementia?
a. Demonstrates impaired judgment
b. Demonstrates impaired concentration
c. Has a history of significant losses or crises
d. Cognitive changes preceded mood changes
ANS: C
Persons with depression often have a history of losses or other experiences which have
predisposed them to depression. In depression-induced pseudodementia, mood changes
precede cognitive changes, and judgment is usually not significantly impaired. Concentration
is affected in both dementia and depression.

13. B and J both have Alzheimers disease. B walks up behind J in the hall and shouts,
Move along, youre blocking the road. Ill take a stick to you. J turns around, shakes his
fist, and shouts, I know what youre up to; youre trying to steal my car. The best action
for the nurse to take would be to:
a. Reinforce reality by telling B that J can walk in the hall, and telling J that B is not
trying to steal his car.
b. Ask the medication nurse to give both patients an as-needed dose of neuroleptic
medication.
c. Separate and distract them by directing one to go to the day room and taking the
other to the activities area.
d. Step between them, saying Gentlemen, please quiet down. We do not permit
violence here.
ANS: C
Separating and distracting patients from their conflict prevents the escalation of the dispute
from verbal to physical acting out. Neither patient loses self-esteem during this intervention,
and PRN medication will probably not be necessary (which is desirable given that many antiagitation drugs have a negative impact on cognition). Both patients appear to be sufficiently
cognitively impaired as to make it unrealistic to expect that they will accept the nurses view
of reality, making reinforce reality likely to be ineffective in this case. Stepping between
two angry, threatening patients is an unsafe action, and trying to reinforce reality during an
angry outburst will probably not be successful when the patients are cognitively impaired.
REF: Text Pages: 387-392, 395-399
14. An elderly patient in the intensive care unit seems to be becoming agitated. She points to
the wall and states, The people in that picture are moving. That doesnt make sense, I
know, but they are. Something is wrong here. Which of the following nursing
interventions would be most beneficial for this patient?
Test Bank
a.
b.
c.
d.
17-7
Place large clocks and calendars on the wall of the patients room.
Have personal belongings brought from home and placed in full view.
Remove the picture, and make sure the patient wears her glasses.
Keep the window blinds closed to prevent glare and overstimulation.
ANS: C
Illusions are sensory misperceptions; the patient misperceives a stimulus that exists in reality.
Eyeglasses help enhance visual perception and reduce perceptual distortions and illusions.
Removing the picture removes an object that the patient has been shown to misperceive,
which in turn led to an increase in distress. Large clocks and calendars would be helpful for
orienting the patient to time and date but would not reduce illusions in general. Personal
belongings might enhance patient comfort by serving as familiar connections to her trusted
home environment. Being able to see out a window helps maintain day/night orientation, and
blinds should be kept open for this reason.
REF: Text Pages: 373, 390, 398

15. A patient with stage 2 Alzheimers disease calls the police, saying an intruder is in her
home. The police officer who investigates the call determines the patient has seen her
own reflection in the mirror and thought an intruder was present. This phenomenon can
be assessed as:
a. hyperorality.
b. aphasia.
c. apraxia.
d. agnosia.
ANS: D
Agnosia is the inability to recognize familiar objects, parts of ones body, or ones own
reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to
the loss of language ability. Apraxia refers to an inability to enact purposeful movements
despite having the motor and sensory abilities to do so, such as being unable to dress.
DIF: Cognitive Level: Comprehension

16. During morning care, the nursing assistant asks a patient with dementia, How was your
night? The patient replies, It was lovely. My husband and I went out to dinner and to a
movie. The nurse who overhears this should make the assessment that the patient is:
a. demonstrating a sense of humor.
b. using confabulation.
c. perseverating.
d. delirious.
ANS: B
Confabulation is the making up of plausible stories or answers to questions in order to conceal
a memory deficit. It is a defensive tactic to protect self-esteem and prevent others from
Test Bank
17-8
noticing memory loss. The patients response was not given facetiously, so it cannot be
assessed as an attempt at humor. Perseveration refers to repeating words or behaviors over
and over. Cardinal signs of delirium are not evident in this scenario.
REF: Text Pages: 373-374, 380-381

17. The outcome that should be established for an elderly patient with delirium caused by
fever and dehydration is that the patient will:
a. return to a premorbid level of functioning.
b. demonstrate motor responses to noxious stimuli.
c. identify stressors negatively affecting self.
d. exert control over responses to perceptual distortions.
ANS: A
The desired overall outcome is that the delirious patient will return to the level of functioning
held before the development of delirium. Option B is an indicator appropriate for a patient
whose arousal is compromised. Option C is too nonspecific to be useful for a patient with
delirium. Option D is an unrealistic indicator for a patient with sensorium problems related to
delirium.
REF: Text Page: 429
TOP: Nursing Process: Planning/Outcomes Identification
18. A family states that the father, who has moderate-stage dementia, is incontinent related to
forgetting where the bathroom is located. An intervention the nurse should suggest to the
family is to:
a. label the bathroom door with a picture of a toilet.
b. have someone take him to the bathroom hourly.
c. place the patient in disposable adult diapers.
d. restrict the patients fluid intake to reduce voiding.
ANS: A
The patient with moderate Alzheimers disease has memory loss that begins to interfere with
activities. This patient may be able to use environmental cues such as labels on doors to
compensate for memory loss. Regular toileting may be helpful, but a 2-hour schedule is often
more reasonable. Adult diapers would be appropriate if less restrictive interventions are
inadequate to address the problem; however, they can be a source of embarrassment and
shame, and interventions which better preserve the patients self-image and self-esteem would
be preferred.
MSC: Client Needs: Safe and Effective Care Environment; Physiological Integrity
Test Bank
17-9
19. A patient with severe dementia can no longer recognize her only daughter and becomes
anxious and agitated when the daughter attempts to reorient her. An alternative the nurse
could suggest to the daughter is to:
a. wear a large name tag.
b. visit her mother less often.
c. talk about experiences theyve shared.
d. place clocks and calendars strategically.
ANS: C
Validating, talking with the patient about familiar, meaningful things, and reminiscing gives
meaning to existence both for the patient and family members. Name tags and clocks or
calendars would help orient the patient but not help overcome her agnosia. Reduced visitation
would be distressing to the daughter and could increase isolation for the patient.

20. Which assessment data suggest a person with confusion has secondary dementia or
pseudodementia?
a. Symptoms developed over a 2-week period.
b. Degree of confusion varies from day to day.
c. Has short-term memory loss; long-term memory is intact.
d. Depression is the patients prevailing mood.
ANS: A
Dementia develops gradually and insidiously over many months and sometimes years.
Significant confusion developing over a period of weeks suggests that the patient does not
have primary dementia but instead has either pseudodementia or secondary dementia. The
degree of confusion can vary in dementias and pseudodementias, and in early stages of
dementia only short-term memory is typically affected (long-term memory deteriorates as the
dementia progresses). Depression can present as pseudodementia because of its effect on
mental functioning, but it also commonly occurs in the early stage of dementia, so simply
having depressed mood does not help distinguish true dementias from pseudo- or secondary
dementias.
REF: Text Pages: 378-379, 381-382

21. The patient need that assumes priority when planning care for a patient with late-stage
dementia is:
a. meaningful verbal communication.
b. promotion of self-care activities.
c. maintenance of nutrition and hydration.
d. preventing the patient from wandering.
ANS: C
In late-stage dementia, the patient often seems to have forgotten how to eat, chew, and
Test Bank
17-10
swallow. Nutrition and hydration needs must be met if the patient is to live. The other issues
are important but not as critical as nutrition.
REF: Text Pages: 384, 387-392

22. Which symptom would suggest that the patient is experiencing delirium instead of
dementia?
a. Altered level of consciousness
b. Disorientation to place and time
c. Wandering of attention
d. Stable autonomic functioning
ANS: A
In delirium, the patients level of consciousness is altered; alertness may be impaired or the
level of consciousness may fluctuate. Both delirium and dementia may involve disorientation
and difficulty focusing and maintaining attention, so these features do not aid in
distinguishing these two disorders. Autonomic nervous system functioning is altered and
unstable in delirium.
REF: Text Pages: 370-371, 378-379

23. A 72-year-old widow has just returned home after 2 weeks in the hospital after a fall. She
lives alone and is visited weekly by her son. She takes digoxin, hydrochlorothiazide, and
an antihypertensive drug. She also has a prescription for diazepam (Valium) as needed for
moderate to severe anxiety. When the visiting nurse stopped by 2 days after discharge, he
found the woman confused and disoriented, with an unsteady gait. The patient asks him
who the small people are who have been living in her house. The patient had not
evidenced any of these symptoms at the time of discharge. Vital signs were unremarkable
except for bradycardia. The nurse correctly deduces that the most likely cause for the
changes seen in the patient is:
a. delirium.
b. dementia.
c. amnestic syndrome.
d. drug toxicity.
ANS: D
Drug toxicity can cause a number of mental status changes, particularly in an elderly or
medically fragile person. Digoxin toxicity can cause a delirium-like presentation that includes
hallucinations (e.g., the small people the patient asked about in this case), and excess valium
ingestion can cause central nervous system depression and confusion. In addition to memory
disturbances and disorientation, delirium is characterized by an abrupt onset of fluctuating
levels of awareness, clouded and/or fluctuating consciousness, and perceptual disturbances,
which are not evident in this case. Dementia has a gradual onset, contrary to the acute nature
of this patients symptoms. Amnestic disorder involves memory impairment without other
cognitive problems.
Test Bank
17-11


24. An 83-year-old man becomes lost while driving. He pulls into a driveway to turn around
and cannot figure out how to put his car in reverse, so he drives into the yard, makes a
circle, and drives back out of the driveway. He is stopped by police, who take him to the
emergency room. The ER diagnoses the patient with stage 2 (moderate) Alzheimers
disease and refers him to the neurology clinic for follow-up. Given this diagnosis, which
behaviors should the clinic nurse anticipate?
a. Does not know todays date
b. Unable to shower without help
c. Denial of mental impairment
d. Inability to recognize family
ANS: C
Persons in the first stage of dementia usually recognize and report changes in functioning but
by the second stage tend to deny that anything is wrong. Persons in stage 2 show some
hygiene impairment but can still complete most tasks with direct assistance. Inability to
recognize loved ones is characteristic of stages 3 and 4.

25. An elderly male develops bradycardia and has a pacemaker surgically implanted.
Although he was lucid preoperatively and has no history of dementia, at 10:00 PM on the
night of his surgery, he becomes disoriented to place and time and insists on going home.
When placed in soft restraints, he becomes hostile and is later caught trying to burn his
way out of the restraints with a cigarette lighter. Which nursing diagnosis should be the
priority diagnosis?
a. Disturbed thought processes
b. Sleep deprivation
c. Risk for injury
d. Ineffective coping
ANS: C
Although all of the diagnoses listed have some application in this situation, the priority
diagnosis when there is a safety concern should be focused on the patients safety. In this case,
there are at least three safety concerns: leaving while medically unstable; presence of delirium
and the medical problem that underlies it; and impaired judgment as seen in the effort to burn
his way out of the restraints. The nursing diagnosis that would best address these concerns is
Risk for injury; the others are less important at this stage.
REF: Text Pages: 375-376, 385-386
MSC: Client Needs: Physiological Integrity; Psychosocial Integrity; Safe and Effective Care
Environment
Test Bank
17-12
way out of the restraints with a cigarette lighter. Which nursing response is most likely to
be therapeutic?
a. Dim the lights in the room so the patient will more likely be able to sleep.
b. Maintain the restraints and have a sitter stay with the patient at night.
c. To monitor his mental status, ask the patient each hour if he knows where he is.
d. Remove the restraints and have a family member stay with him instead.
ANS: D
The patient is likely experiencing a postoperative delirium and is fearful because he is unable
to recognize his surroundings and understand his situation. The presence of a recognized and
trusted loved one will likely decrease the patients anxiety more effectively than staff will be
able to; he will be more likely to accept information from those he trusts than from strangers
about whom he is suspicious. It might seem unwise to remove the restraints, but in this case
they are aggravating the situation by heightening his fear and mistrust, and the presence of
family will likely be more effective at reducing his efforts to leave than will restraints.
Dimming the lighting makes it more difficult for the patient to orient himself to his
surroundings and situation and increases the risk of illusions. Asking orientation questions
repeatedly, especially when orientation has improved, can be very aggravating; patients often
feel as if they are being treated like children or as if they are incompetent. The end result is
greater mistrust and anger towards staff.
Environment
way out of the restraints with a cigarette lighter. Which of the following charted
observations would best indicate that a priority outcome has been achieved?
a. Patient restraints remain intact this shift.
b. No further elopement attempts noted.
c. Pulse consistently 60-64 during night shift.
d. Patient conversing quietly with sitter.
ANS: B
The patient is likely experiencing a postoperative delirium and is fearful because he is unable
to recognize his surroundings and understand his situation. His efforts to leave and go to a
familiar environment (home), when coupled with impaired judgment, place the patient at risk
of harm to self and others. Thus No further elopement attempts indicates that interventions
to calm and orient the patient have been successful and that a key source of risk (fear and its
Test Bank
17-13
resulting elopement efforts) has been reduced. The restraints are an intervention, not an
outcome, and might have been counterproductive in calming the patient. The pulse would be
expected to be regular and within a safe range, given that he is being paced. Conversing
quietly suggests that the patient has calmed but does not provide any information about
possible continued disorientation, fearfulness, impaired judgment, or intent to elope.
TOP: Nursing Process: Evaluation
Environment
28. An immigrant from Korea who has stage 3 Alzheimers disease lives with a daughter, an
Oregon native, in her hometown. During a patient follow-up visit, the visiting nurse
notices that the daughter seems exhausted and has begun to cry. Which nurse response to
the daughter would best reflect an understanding of the familys culture?
a. Being expected to care for ones family can be a significant burden to bear.
b. You seem very tired. Respite care for a day or two each week might help you.
c. Caring for a loved one in need can be both a great honor and a great challenge.
d. There is a very nice nursing home not far from here. Your father might like it
there.
ANS: C
The Korean culture stresses respect and duty towards ones aged family members. As a result,
it would probably be very difficult for a Korean to consider placing an aged loved one in the
care of strangers, even temporarily. Korean American caregivers are more likely to respond to
and benefit from overtures that demonstrate understanding, empathy, and caring and from
assistance to the caregiver as they provide care.
REF: Text Page: 378

29. A woman with Alzheimers disease has significant apraxia and poor hygiene. Which
intervention would be most appropriate for ensuring that the patient completes a shower?
a. Remind her of the need for a shower and where the shower is, and repeat this every
30 minutes until the shower is completed.
b. Discuss with her the importance of showers as part of daily self-care, and elicit and
resolve any obstacles to the patients showering.
c. Walk her to the shower, and provide occasional reminders of what she should do
next if she seems to be unsure or begins to repeat previous actions.
d. Walk her to the shower, assist her to undress, start the water, supply the soap and
washcloth, and instruct her to rub her face with the washcloth.
ANS: D
Apraxia is the inability to complete tasks despite having the sensory and motor capacity to do
so. It is seen in significant levels in stage 3 Alzheimers disease and requires the full
assistance of a caregiver or staff person, who must patiently provide simple, concrete, step-bystep directions, with each direction given one at a time when the patient is ready to progress to
Test Bank
17-14
the next step. Simply reminding the patient to shower, educating her about hygiene, assisting
her to go to the shower room, or providing reminders would not be therapeutic for patients
with significant apraxia. They lack the ability to remember or enact any of the steps involved
in a complex task and require directions for each action and step involved in the process.
REF: Text Page: 383
MSC: Client Needs: Health Promotion and Maintenance; Physiological Integrity
30. You are a nurse meeting for the first time with a stage 3 Alzheimers patient who is newly
referred to your home health agency. Which assessment data about the patient and
caregiver(s) would be most important to acquire during your first visit to the familys
home?
a. Is the house design such that patient access to exits and stairways can be restricted?
b. Does the family understand that the disease is likely to prove fatal within 3 to 5
years?
c. What resources is the patients family able to access in their particular community?
d. What activities or memories are most comforting and calming for the patient?
ANS: A
Wandering, impulsivity, and impaired judgment are significant issues in stage 3 Alzheimers
disease. Unrestricted access to exits and stairways would permit elopement or present a
significant fall risk, respectively, and of the assessment choices here, should be the assessment
priority because they so directly affect the patients safety. The other choices are not essential
to cover during the initial assessment.
31. Which intervention would best address the nursing diagnosis of Imbalanced nutrition for
elderly patients in stages 2 to 3 of Alzheimers disease?
a. Monitor the frequency and characteristics of bowel movements.
b. Offer finger foods the patient can take away from the table.
c. Monitor intake and output, and take patient weights each week.
d. Provide protein-dense foods to provide for neurological regrowth.
ANS: B
Persons in stages 2 and 3 of Alzheimers are prone to distractibility and wandering, so
providing finger foods that they can eat away from the table is likely to increase the amount of
nutrients they consume. Bowel movements are not a reliable indicator of nutritional status.
Elderly people with Alzheimers may forget to eat and often have very erratic intakes, putting
them at risk for dehydration, which is best monitored via daily weights, since hydration can
change so quickly in an elderly, confused person. Nutrient-dense foods would be desirable,
but protein-dense foods would not present a balanced diet; furthermore, treatments at this time
do not result in neuroregeneration.
Test Bank
17-15
MULTIPLE RESPONSE
1.
a.
b.
c.
d.
e.
f.
The head nurse on a unit that serves persons with cognitive impairment is concerned
about her staff, many of whom seem to be becoming burned out by their challenging
work. Which response by the head nurse is most likely to minimize staff frustration and
burnout on the unit? Select all that apply.
Educate staff regarding realistic expectations for this patient population.
Arrange for 12-hour shifts so that staff can have more days off per week.
Guide staff to use small, realistic goals as their measure of patient progress.
Provide for after-work activities such as meeting at taverns for happy hours.
Encourage and support staff in taking good care of their own health.
Rotate staff shifts and assignments to vary their work and keep it fresh.
ANS: A, C, E
Working with high concentrations of persons with dementia can be very challenging. Such
work focuses on maintaining function and quality of life rather than the more traditional
nursing goals of improvement and recovery from illness. Helping staff to understand and
adjust to this difference helps them to have more realistic expectations of their work, and in
turn, to experience fewer disappointments in their work. Setting small, realistic patient goals
works similarly to enable staff to see progress and to have more positive work experiences.
Taking care of ones own health enables staff to be more resilient in the face of the emotional
and physical demands of their work. Twelve-hour shifts may exceed the emotional and/or
physical stamina of many staff in a way that is not fully counterbalanced by the additional
days off each week. Encouraging consumption of alcohol as a coping technique promotes
maladaptive coping. Rotating shifts and assignments tends to keep staff off balance and
deprives them of having enough time with patients to see their improvement.
REF: Text Page: 384
2.
a.
b.
c.
d.
e.
f.
A patient with vascular dementia wanders from his home. His wife is unable to obtain
adequate sleep because most of his wandering efforts occur during the night. Which
intervention(s) would be appropriate for this problem? Select all that apply.
Enroll the patient in a Safe Return program.
Place locks and alarms at the tops of all exits.
Arrange for a sitter to watch the patient at night.
Request an order for a long-acting benzodiazepine qhs.
Use signs to show where desired items are located.
Promote high levels of activity during the day.
ANS: A, B, E, F
Interventions that reduce patient wandering, restrict wandering to safe environments, and
preserve the patients safety if he does wander are desirable. These include enrolling the
patient in programs that use police and other resources to watch for wandering patients and
Test Bank
17-16
enable them to return the patient to his home; placing locks and alarms at the top of exit doors
(where the patient will be less likely to notice them and defeat them); using signage to help
the patient located desired rooms and objects so he does not wander looking for them; and
promoting high levels of daytime activity to tire the patient and promote sleep during the
night. A sitter is not likely to be a practical solution to a chronic problem because of the
expense and access issues. Long-acting benzodiazepines are not a good choice for sedation in
cognitive impairment because they increase the risk of delirium and may act cumulatively to
increase fall risk, worsen confusion, and/or produce excess sedation or daytime sedation.
3.
a.
b.
c.
d.
e.
f.
REF: Text Pages: 372, 390-393

Which information would be important to incorporate when teaching about medications

for dementia in a caregivers support group? Select all that apply.
Antipsychotic medications have been shown to be the most useful category of
drugs in reducing behavioral problems in dementias.
Most currently available medications slow the progress of the disease in 20% to
50% of patients but usually do not significantly improve functioning.
None of the currently available medications for dementias provide a cure, and
although some vitamins may be helpful, research so far is inconclusive.
Certain antidepressant drugs are sometimes helpful in improving sleep, reducing
irritability, and lessening anxiety.
Elderly persons require more careful dosing, more monitoring, and are more
sensitive to side effects, particularly when taking multiple drugs.
Certain anticonvulsants seem to improve memory and judgment in the early stages
of many dementias.
ANS: B, C, D, E
No current drugs cure Alzheimers and other primary dementias, but they may slow the
progression of the disorder and in some cases may produce modest improvement in behavior
and cognition. Elderly persons are more sensitive to side effects and cumulative drug effects;
they require greater care and monitoring to use these medications safely. Folate, B6, B12, and
other vitamins may be of some value in dementias, but the research on vitamins, minerals, and
dietary supplements in general is largely inconclusive. Select SSRI antidepressants may
benefit sleep, irritability, and anxiety. Select antipsychotic drugs are sedating, but research
does not support the notion that they improve the behavioral or cognitive dysfunctions in
dementia. Select anticonvulsants may reduce aggression and emotional lability but do not help
memory or judgment.

4.
A patient with Alzheimers disease has been determined to have a dressing/grooming selfcare deficit. Which intervention(s) would be appropriate for this nursing diagnosis?
Select all that apply.
a. Replace personal clothing with gym clothes that all match each other.
b. Label the patients clothing with his name and name of the item.
Test Bank
c.
d.
e.
f.
17-17
Provide clothing with elastic waistbands and hook-and-loop closures.

Administer anxiolytic medication before bathing and dressing.
If the patient is resistive, use distraction; then try again after a short interval.
If the patient moves too slowly to accomplish the task, perform it for him.
ANS: B, C, E
Labeling the patients clothing with his name and the name of the item makes it easier for the
patient to distinguish his clothes and choose items appropriately. Elastic waistbands and hookand-loop closures simplify the motor skills needed in the dressing process. Persons with poor
short-term memory tend not to sustain a particular mood; waiting and trying again often finds
them in a different mood, particularly if a distracting activity is used between tries. Replacing
the patients personal clothing with new and unfamiliar clothing can be disorienting and can
aggravate confusion. Antianxiety medications can cause sedation, increase confusion, and
impair fine motor skills. Completing tasks for the patient reduces practice opportunities,
hastening the loss of those skills.
5.
a.
b.
c.
d.
e.
f.

An 83-year-old man becomes lost while driving. He pulls into a driveway to turn around
and cannot figure out how to put his car in reverse, so he drives into the yard, makes a
circle, and drives back out of the driveway. The police who observe this action pull him
over, quickly determine that he is cognitively impaired, and take him to the emergency
room. Which evaluations would the emergency room nurse expect to see ordered? Select
all that apply.
Folate and b12 levels
Electrolytes and serum creatinine
Hearing and vision screening
Psychological testing
Mental status examination
Brain imaging
ANS: A, B, C, E, F
Many medical and psychiatric disorders can present as dementia and must be ruled out before
a diagnosis of dementia is reached. Evaluation must address all issues that potentially affect
mental status, including nutritional elements necessary for brain function, metabolic factors,
sensory changes, and brain imaging to detect structural changes such as atrophy. A complete
mental status examination identifies nervous system deficits such as impaired memory or
executive function. The only examination here that is not typically performed in the
emergency room is psychological testing, which is a lengthy process that requires a
psychologist and thus is rarely feasible in the emergency room.
TOP: Nursing Process: Assessment, Planning
Test Bank
6.
a.
b.
c.
d.
e.
f.
17-18
You are a home health nurse completing the initial care plan for a patient with stage 3
Alzheimers disease. Which data are essential to consider in creating the initial care plan?
Select all that apply.
Concerns, experiences and preferences of the caregiver(s)
Patients usual behavioral patterns, such as sleep and intake
Patients scores on standardized dementia assessment tools
What expectations are realistic for this patient at this time?
When the family/caregivers last had an opportunity for respite
Knowledge and skill level of the patients caregiver(s)
ANS: A, B, D, F
The initial care plan should incorporate the experiences and preferences of the caregivers and
the patient (to gain their support and avoid repeating approaches that have been unsuccessful
or unimportant in the past). It should also build on and be consistent with the patients usual
patterns of behavior (where feasible). Another important element to include in planning care is
what expectations might be realistic for a particular patients circumstances, including the
knowledge and skill levels of his caregiver(s). Although structured assessment rating scales
can be useful, they are not necessarily critical for the initial care plan and may not provide as
much practical guidance as the experiences of the patients caregivers. Caregiver burnout is
always a concern, so information about their coping status and access to respite is important
but not usually essential for the initial care plan.
MSC: Client Needs: Safe and Effective Care Environment; Physiological Integrity;
Psychosocial Integrity

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Varcarolis: Foundations of Psychiatric Mental Health Nursing, 6th Edition

Chapter 17: Cognitive Disorders

REF: Text Pages: 375, 381

REF: Text Pages: 373, 381, 384

A patient in a dimly lit room demonstrates fluctuating levels of consciousness, disturbed

REF: Text Pages: 370, 381

REF: Text Page: 381

Hypermetamorphosis, the process of touching everything in ones environment as a way of

REF: Text Pages: 382-384

REF: Text Page: 379

REF: Text Pages: 371-372

REF: Text Pages: 373, 390, 398

REF: Text Pages: 381-384

REF: Text Pages: 373-374, 380-381

REF: Text Pages: 387-390

REF: Text Pages: 378-379, 381-382

REF: Text Pages: 384, 387-392

REF: Text Pages: 370-371, 378-379

DIF: Cognitive Level: Analysis

REF: Text Pages: 375, 381

REF: Text Pages: 382-384

REF: Text Page: 378

TOP: Nursing Process: Implementation

MSC: Client Needs: Physiological Integrity

REF: Text Pages: 372, 390-393

Which information would be important to incorporate when teaching about medications

REF: Text Pages: 392-395

Provide clothing with elastic waistbands and hook-and-loop closures.

REF: Text Pages: 388, 390

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