Chapter 13: Delirium and Dementia Linton: Medical-Surgical Nursing, 7th Edition

Medical-Surgical Nursing 7th Edition Linton Test Bank
Chapter 13: Delirium and Dementia

Linton: Medical-Surgical Nursing, 7th Edition
MULTIPLE CHOICE
1. The family of a patient with Alzheimer disease asks the nurse, “When will my mother quit
being so confused?” On what information regarding dementia should the nurse base a
response?
a. It is a short-term confusional state that is typically reversible.
b. It is a state of confusion caused primarily by medications.
c. It is a state of confusion that usually begins abruptly and lasts a short period.
d. It is a syndrome that is chronic and irreversible.
ANS: D
Alzheimer disease is a type of dementia that is chronic and irreversible. Delirium is a
short-term confusional state that has a sudden onset and is typically reversible.
DIF: Cognitive Level: Knowledge REF: p. 205 OBJ: 2

TOP: Dementia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Basic Care and Comfort
2. A nurse is admitting a patient who has been diagnosed as having confusion. What is the most
important observation that the nurse should make regarding this patient?
a. Eating, drinking, and sleeping patterns
b. Behavior, orientation, memory, and sleeping habits
c. Urinary and bowel elimination habits
NURSpatterns
d. Talking, walking, and sleeping INGTB.COM
ANS: B
The first step in assessing a confusional state is to observe the patient’s behavior, orientation,
memory, and sleeping habits.
DIF: Cognitive Level: Comprehension REF: p. 206 OBJ: 6

TOP: Confusion Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
3. While a nurse is dressing a patient who has dementia as a result of Huntington disease, the
patient states, “I don’t want to wear clothes today” and begins to resist help putting on her
clothes. What is the nurse’s most appropriate action?
a. Tell the patient that she must wear clothes or she cannot see her family later.
b. Get another nurse to help her force the patient to get dressed.
c. Talk to the patient about her family coming this afternoon and continue to assist
the patient gently with dressing.
d. Let the patient go without clothes but make her stay in her room.
ANS: C
When patients with dementia resist activities such as bathing or dressing, avoiding
confrontations and diverting their attention elsewhere are best.
DIF: Cognitive Level: Application REF: p. 211 OBJ: 6

TOP: Resisting Care KEY: Nursing Process Step: Planning
NURSINGTB.COM
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
4. What are the adaptations to interventions that the Cognitive Developmental Approach (CDA)
to caring for patients with dementia designed to achieve?
a. Increase cognitive abilities.
b. Adapt environment to patient.
c. Offer a wide variety of choices.
d. Abolish irrational fears.
ANS: B
The CDA adapts implementations based on the patient’s cognitive abilities as they are,
modifies the environment, and offers limited choices.

TOP: Cognitive Developmental Approach
KEY: Nursing Process Step: Implementation
5. A nurse is gathering information from the family of a patient who is experiencing confusion.
What important question should the nurse ask the family?
a. “Are you sure she is confused? Maybe she just didn’t hear what you were saying.”
b. “When did you first think she might be confused? Tell me exactly what
happened.”
c. “Did something bad happen to her during her childhood?”
d. “How can you say she is confused? She knows who she is.”
ANS: B
Family members may be ableNto RprovideGhelpful information when the patient cannot. The
U SIof
nurse should ask when the symptoms TB.COstarted
N confusion M
and whether the confusion is
constant or intermittent.

TOP: Assessing Confusion KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity
6. The family of a patient with dementia expresses concern to the nurse about the patient
wandering at night. They are afraid that the patient might get up while they are sleeping and
go outside. What is the best advice for the nurse to provide?
a. Apply a vest restraint at night.
b. Perform constant reality orientation.
c. Learn some behavior modification techniques.
d. Put new locks on the outside doors in new places.
ANS: D
Take advantage of the fact that patients with dementia are usually unable to learn new things.
They will probably not be able to figure out how to work a new lock.

TOP: Dementia Safety KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
NURSINGTB.COM
7. A nurse is planning for the nutritional needs of a patient with Alzheimer disease. What is the
best plan to have the dietary department provide?
a. Pureed diet to be fed with a syringe
b. Foods that the patient can cut up to keep busy and not lose interest in eating
c. Finger foods several times a day
d. High-protein liquid diet
ANS: C
Small, frequent meals are less confusing to patients. Finger foods high in protein and
carbohydrates allow patients to feed themselves more easily.

TOP: Nutritional Needs KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
8. What initial nursing action should be implemented when assisting a patient with dementia to
dress?
a. Hand the patient her clothes and ask her to put them on.
b. Hand the patient each article of clothing separately and ask her to put it on.
c. Assist her with each article, giving specific instructions such as, “Put your arm in
this hole.”
d. Put the patient’s clothes on without assistance from the patient.
ANS: C
The goal should be to maintain the highest level of functioning possible, but tasks must be
broken down into individual steps to be performed one at a time.
DIF: Cognitive Level: Application

NURSINGREF: p. 209
TOP: Self-Care Needs TB.C
KEY: OM ProcessOBJ:
Nursing
6
Step: Implementation
9. Reality orientation is helpful for some patients with confusion. What patient diagnosis is most
appropriate for the nurse to implement this technique?
a. Organic brain syndrome
b. Senile dementia
c. Senility
d. Acute confusional state (delirium)
ANS: D
Acute confusional state is another name for delirium. The other choices are other names for
dementia. Reality orientation may be helpful for patients with delirium but tends to agitate
patients with dementia.

TOP: Reality Orientation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
10. A nurse is assessing a patient for the possibility of confusion. What two major types of
confusion should the nurse be aware of to appropriately assess this patient?
a. Acute and chronic senility
b. Temporary and permanent confusion
c. Delirium and dementia
NURSINGTB.COM
d. Senility and senile dementia

ANS: C
The two major types of confusion are acute confusional states, or delirium, and chronic
confusion dementia.

TOP: Types of Confusion KEY: Nursing Process Step: Planning
11. A patient with delirium repeatedly cries out for her husband. What is the most appropriate
initial nursing intervention?
a. Administer Haldol as ordered.
b. Apply restraints so that the patient will not harm herself.
c. Calmly tell the patient that she is in the hospital and that her husband is not there.
d. Call the husband and tell him that he needs to come and stay with his wife.
ANS: C
Anyone dealing with a delirious patient should be calm, warm, and reassuring. Frequent
orientation to the surroundings and situation is important as well.

TOP: Delirium KEY: Nursing Process Step: Implementation
12. When admitting a patient who has recently become confused, the nurse asks the family for a
list of all the medications that the patient is currently taking. Which medication identified by
the family should the nurse be aware could be causing confusion?
a. Amoxicillin
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b. Acetaminophen
c. Furosemide
d. Digoxin
ANS: D
Drugs that most commonly cause confusion include anticholinergics, digoxin, histamine-2
receptor blockers, benzodiazepines, nonsteroidal anti-inflammatory drugs, and many
antiarrhythmic and antihypertensive medications.

TOP: Confusion Due to Medications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
13. A patient has been admitted with a diagnosis of confusion. The physician’s admission note
states that he wants to assess for delirium versus dementia. What should the nurse be aware
that the main differences include?
a. Whereas delirium usually lasts several years, dementia lasts only a few days.
b. Whereas delirium usually has sudden onset and is reversible, dementia is chronic
and irreversible.
c. Whereas dementia is usually caused by medications, delirium is not.
d. Whereas dementia is easily treated with reality orientation, delirium is not.
ANS: B
NURSINGTB.COM
Delirium is a short-term, confusional state that has a sudden onset and is typically reversible.
Dementia is a syndrome that is often chronic and irreversible.
DIF: Cognitive Level: Knowledge REF: pp. 203-206 OBJ: 4

TOP: Delirium versus Dementia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Psychosocial Adaptation
14. A nurse has found a patient with delirium in other patients’ rooms several times. What is the
best action by the nurse?
a. Firmly tell the patient that he must stay out of other patients’ rooms and tell him to
return to his room.
b. Take him back to his room and put him in bed with the side rails up.
c. Take him to the nurses’ station and let him visit for a while.
d. Administer a dose of lorazepam (Ativan) as ordered.
ANS: C
Avoid using physical restraints, which tend to increase anxiety and agitation. Sitting at the
nurses’ station will allow the nurses to monitor his activity and frequently orient him to his
surroundings.

TOP: Delirium KEY: Nursing Process Step: Implementation
15. A nurse in a long-term care facility is taking patients to the dining room for lunch. She asks
the patient who has been diagnosed with delirium if she is ready to go eat lunch. The patient
does not respond. What should be the nurse’s next action?
a. Take the patient by the armNUand
RSlead
INGherTB.C M room.
to theOdining
b. Assist the patient to bed and bring her lunch to her.
c. Tell the patient that she can go to the dining room whenever she gets hungry.
d. Ask the patient again if she is ready to go eat lunch.
ANS: D
A patient with delirium may have difficulty focusing or paying attention, and questions must
often be repeated several times.

TOP: Communication KEY: Nursing Process Step: Implementation
16. A patient asks a nurse what causes dementia. What two most prevalent types of dementia
should the nurse consider before responding?
a. Pick disease and Huntington disease
b. Alzheimer disease and vascular dementia
c. Creutzfeldt-Jakob disease and Pick disease
d. Vascular dementia and Huntington disease
ANS: B
Alzheimer disease and vascular dementia are the two most prevalent types of dementia.

TOP: Types of Dementia KEY: Nursing Process Step: Implementation
NURSINGTB.COM
MSC: NCLEX: Physiological Integrity: Psychosocial Adaptation
17. A nurse is assessing a patient for delirium versus dementia. What should the nurse expect the
patient with dementia to display?
a. Intermittent fear affect
b. Perplexity affect
c. Bewilderment affect
d. Flat affect
ANS: D
The patient with dementia will have a flat or indifferent affect. The other three choices would
be presented by a patient with delirium.

TOP: Dementia Affect KEY: Nursing Process Step: Assessment
18. A nurse is taking a patient who has Alzheimer disease to the bathing room for a tub bath. The
patient states, “Please don’t make me take a bath today. I am so afraid that I will be washed
down the drain.” What is the nurse’s best response?
a. “Don’t be silly; there’s no way you would fit in the drain.”
b. “I am your nurse, and I will stay with you, so you shouldn’t be afraid of your
bath.”
c. “Let’s go back to your room, and I will bathe you there.”
d. “Today is your day for a bath.”
ANS: C
The nurse should recognize irrational
N R IfearsG and
B.C arrange
M alternative ways to give personal care.
U S N T O
TOP: Alzheimer Disease KEY: Nursing Process Step: Implementation
19. Which characteristics are most likely to be present in the patient with dementia?
a. Forgets things relatively quickly and is usually unable to learn new things
b. Can remember new tasks but will forget any previously taught tasks
c. Cannot learn new information but will probably remember anything you ask about
the past
d. Responds well to reality orientation and needs to have a flexible schedule
ANS: A
Keeping in mind the following two important concepts when taking care of patients with
dementia is helpful: (1) they usually forget things relatively quickly, and (2) they are usually
unable to learn new things.
DIF: Cognitive Level: Comprehension REF: p. 211 OBJ: 1 | 4

TOP: Dementia KEY: Nursing Process Step: Planning
20. A patient is displaying confusion, which began very suddenly and lasted less than 1 week.
What should the nurse suspect is present?
a. Dementia
NURSINGTB.COM
b. Delirium
c. Symptoms of Huntington disease
d. Senile dementia
ANS: B
Delirium begins abruptly and generally lasts a short period. It usually lasts 1 week and rarely
lasts longer than 1 month.

TOP: Acute Confusion KEY: Nursing Process Step: Assessment
21. A nurse is preparing a room for a patient being transferred from the emergency department
with a diagnosis of delirium. What should the nurse ensure in regard to the room?
a. Brightly lit
b. Shared by another patient
c. Visible from the nurses’ station
d. Dark and quiet
ANS: C
The patient should be in a private room with continual supervision. The room should be quiet
and uncluttered, and lighting should be soft and diffuse to avoid shadows.

TOP: Environmental Consideration KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
22. A nurse caring for a patient with dementia notices that the patient stays awake most of the
N R I G B.C M
night. What is the nurse’s mostUappropriate
S N Taction? O
a. Give a prescribed sleeping medication.
b. Tell the patient that it is nighttime and that she must go to sleep.
c. Check the patient’s record to see whether she is sleeping during the day.
d. Put the patient to bed and put the side rails up.
ANS: C
Sleep and awakening are often reversed in patients with dementia. Trying to keep the patient
awake during the day is helpful.

TOP: Sleep Patterns KEY: Nursing Process Step: Implementation
23. A nurse is discussing home care of a patient with dementia with the patient’s family. What
should the nurse advise the family do to prevent the patient from wandering?
a. Apply a vest restraint to keep the patient in bed or in a chair.
b. Put locks on any doors that it would be dangerous for the patient to open (e.g.,
outside doors, medicine cabinet).
c. Have someone remind the patient at least every 2 hours that he or she must not go
outside by him or herself.
d. Set up a reward system for the times the patient stays where the family has
requested.
NURSINGTB.COM
ANS: B
Patients with dementia must have the environment adapted to them rather than trying to adapt
the patient to the environment. They usually forget things relatively quickly and will probably
not remember what you have told them.

TOP: Wandering KEY: Nursing Process Step: Planning
24. A patient asks a nurse, “My doctor says I get confused sometimes because I have vascular
dementia. What caused me to have that?” What is the most appropriate response by the nurse?
a. “It is usually caused from damage to brain cells because of inadequate blood
supply, like a small stroke.”
b. “It is probably just some abnormal electrical activity in your brain.”
c. “You probably have a brain tumor.”
d. “I’m sure he will explain it to you later.”
ANS: A
Patients with vascular dementia often have had a series of small strokes that cause progressive
damage.

TOP: Vascular Dementia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
25. What should nursing care focus on to best support a patient with mild cognitive impairment
(MCI)?
a. Reorienting the patient toNtheRphysical
U SINGTenvironment
b. Developing strategies to improve memory
B.COM
c. Assisting with dressing and eating
d. Establishing toileting schedules
ANS: B
Persons with MCI need strategies for improving their memory. These persons have memory
impairment but have otherwise normal cognition.
DIF: Cognitive Level: Comprehension REF: pp. 204-205 OBJ: 1 | 6

TOP: MCI KEY: Nursing Process Step: Planning
26. An 80-year-old patient with delirium related to high fever is hallucinating about large animals
being in the room. What is the most reassuring nursing response to this patient?
a. “Yes, the animals are in here, but they are sound asleep.”
b. “I’m going to turn out the lights so you won’t have to look at the animals.”
c. “You are in the hospital. There are no animals in this room.”
d. “The hospital does not allow animals in the room.”
ANS: C
Reorientation and presentation of reality are helpful with patients who have delirium.

TOP: Hallucinations KEY: Nursing Process Step: Implementation
NURSINGTB.COM
MULTIPLE RESPONSE
1. What are believed to be causes of Alzheimer disease? (Select all that apply.)
a. Amyloid deposits in the brain
b. Excess of acetylcholine
c. Neurofibrillary tangles
d. Infiltration of Lewy bodies
e. Series of small strokes
ANS: A, C
The cause of Alzheimer disease is still unclear, but protein deposits of amyloid have been
found during autopsies of the brains of patients with Alzheimer disease, as well as tangled
neurofibers. In addition, a deficiency of acetylcholine exists. Lewy bodies are associated with
another type of dementia, and small strokes are thought to be the cause of vascular dementia.

TOP: Etiology of Alzheimer Disease KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
COMPLETION
1. When a normally oriented 87-year-old resident in a long-term care facility exhibits acute
confusion, the nurse should first assess for a(n) ______.
ANS: NURSINGTB.COM
infection
Infections, especially those that cause fever, can result in an older patient becoming confused
or delirious.
DIF: Cognitive Level: Application REF: pp. 203-204 OBJ: 3

TOP: Infections as Cause of Acute Confusion
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. An 80-year-old woman who has Alzheimer disease is restless, wanders during mealtimes, and
will not sit down to eat. The nurse assisting with writing the care plan prioritizes the following
interventions for the goal: The patient will eat at least 25% of each meal. ______ (Prioritize
the options in sequence, from the most therapeutic to the least therapeutic. Do not separate
answers with a space or punctuation. Example: ABCD.)
a. Place her in a chair with a vest restraint.
b. Assign a nursing assistant (NA) to feed her.
c. Give her a high-protein drink in a small cup to carry with her.
d. Offer peanut butter crackers as she passes by.
e. Leave her alone. She will eat when she is hungry.
ANS:
CDBAE
NURSINGTB.COM
Offering a high-energy drink in a small cup partially meets the goal without further agitating
the patient. Offering a cracker accomplishes the same thing, but accurate evaluation of
whether the crackers are eaten or just dropped might be difficult. Assigning an NA to feed her
may agitate her further and reduce her intake even more; in addition, it may not be the best
use of available personnel. Placing her in a chair with a vest restraint is not a very desirable
intervention and may not encourage her to eat. Leaving her alone does not meet the goal nor
does it reduce the nutrition deficit.
DIF: Cognitive Level: Analysis REF: pp. 209-210 OBJ: 6

TOP: Nutrition Deficit KEY: Nursing Process Step: Implementation
NURSINGTB.COM
NURSINGTB.COM

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Medical-Surgical Nursing 7th Edition Linton Test Bank

Chapter 13: Delirium and Dementia

DIF: Cognitive Level: Knowledge REF: p. 205 OBJ: 2

DIF: Cognitive Level: Comprehension REF: p. 206 OBJ: 6

DIF: Cognitive Level: Application REF: p. 211 OBJ: 6

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

DIF: Cognitive Level: Knowledge REF: p. 211 OBJ: 6

DIF: Cognitive Level: Application REF: p. 206 OBJ: 6

DIF: Cognitive Level: Application REF: p. 211 OBJ: 6

DIF: Cognitive Level: Comprehension REF: p. 209 OBJ: 6

DIF: Cognitive Level: Application

DIF: Cognitive Level: Comprehension REF: p. 208 OBJ: 6

d. Senility and senile dementia

DIF: Cognitive Level: Knowledge REF: p. 203 OBJ: 1

DIF: Cognitive Level: Application REF: p. 208 OBJ: 6

DIF: Cognitive Level: Comprehension REF: p. 206 OBJ: 3

DIF: Cognitive Level: Knowledge REF: pp. 203-206 OBJ: 4

DIF: Cognitive Level: Application REF: p. 208 OBJ: 6

DIF: Cognitive Level: Application REF: p. 203 OBJ: 6

DIF: Cognitive Level: Knowledge REF: p. 205 OBJ: 2

MSC: NCLEX: Physiological Integrity: Psychosocial Adaptation

DIF: Cognitive Level: Comprehension REF: p. 207 OBJ: 4

DIF: Cognitive Level: Comprehension REF: p. 211 OBJ: 1 | 4

DIF: Cognitive Level: Comprehension REF: p. 203 OBJ: 4

DIF: Cognitive Level: Comprehension REF: p. 211 OBJ: 6

DIF: Cognitive Level: Application REF: p. 210 OBJ: 6

DIF: Cognitive Level: Application REF: p. 211 OBJ: 6

DIF: Cognitive Level: Knowledge REF: p. 205 OBJ: 1

DIF: Cognitive Level: Comprehension REF: pp. 204-205 OBJ: 1 | 6

DIF: Cognitive Level: Application REF: p. 208 OBJ: 6

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

DIF: Cognitive Level: Knowledge REF: p. 205 OBJ: 2

DIF: Cognitive Level: Application REF: pp. 203-204 OBJ: 3

DIF: Cognitive Level: Analysis REF: pp. 209-210 OBJ: 6

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