Author Question: An older adult drove to a nearby store but was unable to remember how to get home or state an ... (Read 39 times)

azncindy619 · **on:** Jul 19, 2018

An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police took the person home, the spouse reported frequent wandering into neighbors' homes. Alzheimer's disease was subsequently diagnosed.

Which stage of Alzheimer's disease is evident?

a. 1 (mild)
b. 2 (moderate)
c. 3 (moderate to severe)
d. 4 (late)

Question 2

What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?

a. Bathing/hygiene self-care deficit, related to altered cerebral function, as evidenced by confusion and inability to perform personal hygiene tasks
b. Risk for injury, related to altered cerebral function, misperception of the environment, and unsteady gait
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 hiding from imagined ferocious dogs

maaaaaaaaaa · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

ANS: B
In stage 2 (moderate), deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. Hygiene may begin to deteriorate. Stage 3 (moderate to severe) finds the individual unable to identify familiar objects or people and needing direction for the simplest of tasks. In stage 4 (late) the ability to talk and walk are eventually lost and stupor evolves.

Answer to Question 2

ANS: B
The physical safety of the patient is the highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful; when the patient exercises poor judgment; and when the patient's sensorium is clouded. The other diagnoses may be concerns but are lower priorities.