A nurse is caring for a 92-year-old female patient who was admitted to the hospital 1 day after she ...

A nurse is caring for a 92-year-old female patient who was admitted to the hospital 1 day after she had outpatient cataract surgery.
 
  The patient who lives in an assisted living facility became very confused and agitated and was found wandering in the lobby of the building in her nightgown. She refused to return to her room and stated that there were bad men in her room. The patient has a history of dementia, diabe-tes, heart failure, and is on seven different medications. She was widowed 1 year ago. The nurse suspects that she has delirium. What are the patient's risk factors for delirium? (Select all that ap-ply.)
  a. Age of 92
  b. Residing in an assisted living facility
  c. History of dementia
  d. Female gender
  e. Recent cataract surgery

Question 2

Which intervention to manage wandering in clients in a long-term care facility should be imple-mented? (Select all that apply.)
 
  a. Camouflaging doorways
  b. Close observation to identify the person's individual patterns
  c. Engaging the person in social interactions
  d. Using physical restraints to prevent wan-dering to maintain safety
  e. Providing enclosed pathways for walking

Question 3

A nurse is caring for a patient with a diagnosis of delirium. Which of the following is an ex-pected assessment finding for this patient?
 
  a. Normal attention span
  b. Fluctuation in symptoms
  c. Normal sleep cycle
  d. Increased appetite

Question 4

Which information will the nurse manager include when discussing the major differentiation be-tween delirium and dementia with novice nurses? (Select all that apply.)
 
  a. The delirious client learns to make up an-swers to hide his or her confusion.
  b. Delirium requires increased monitoring at night.
  c. The client diagnosed with dementia gen-erally looks frightened.
  d. Dementia results in a steady decline in cognitive abilities.
  e. Delirium is characterized by fluctuations in alertness.

Question 5

An older client admitted to the hospital after having sustained a fall at home is diagnosed with a right hip fracture and experienced a surgical reduction of the fracture.
 
  At 2:30 AM, she awakens from sleep insisting that her daughter is in the other room and wants to see her. Attempts to reorient her to the surroundings are unsuccessful. In reviewing the client's record, what data would be considered a primary risk factor for the delirium?
  a. History of dementia
  b. Death of the client's husband last month
  c. The client's age
  d. History of cardiac disease

Question 6

An older client diagnosed with dementia resides with his daughter. When the homecare nurse visits, the daughter tearfully tells the nurse that her father scratched her hand and cursed at her when she was attempting to feed him.
 
  She states, I don't know why he hates me and wants to hurt me. I try so hard to take good care of him. I love him. How will the nurse respond to the client's daughter?
  a. Let's think about what you may have done to anger your father?
  b. Let's try to figure out what your father was trying to say with his behavior.
  c. Scratching is usually a sign of untreated pain. Do you think your father is in pain?
  d. Maybe you should consider having a home health care provider take over re-sponsibility for your father's physical care.

Question 7

Which intervention best addresses the principle that is the basis for communicating with a client experiencing postsurgical delirium?
 
  a. Reminding the client that delirium is gen-erally acute and reversible
  b. Assuming that the client's statements are an attempt to express needs
  c. Allowing the client sufficient time to for-mulate an answer to questions
  d. Using nonverbal communication tech-niques to communicate with the client