Author Question: A nurse is assessing an older patient with new onset confusion using the Confusion Assessment Method ... (Read 64 times)

rmenurse · **on:** Jul 11, 2018

A nurse is assessing an older patient with new onset confusion using the Confusion Assessment Method (CAM). The nurse understands that in order to have a diagnosis of delirium when using the CAM, the patient must exhibit which of the following?

(Select all that apply.)
a. Acute onset of symptoms or fluctuating course
b. Inattention
c. Disorganized thinking
d. Altered level of consciousness
e. Alteration in level of physical activity

Question 2

A nurse in a long term care facility is concerned that a 94-year-old resident with dementia is los-ing weight.

Upon assessment, the nurse notes that the resident, who is able to feed herself independently, consumes less than 50 of each of her meal trays. Which of the following strategies can the nurse utilize to improve this resident's intake? (Select all that apply.)
a. Assign a nursing assistant to feed the res-ident.
b. Assign a nursing assistant to sit with the resident as the resident eats.
c. Serve the resident finger foods.
d. Serve the resident one dish at a time.
e. Alter the dining ambience to reduce dis-tractions.

nguyenhoanhat · **Reply #1 on:** Jul 11, 2018

Answer to Question 1

ANS: A, B
In order to be diagnosed with delirium, using the CAM, the individual must have acute onset or fluctuating course and inattention and either disorganized thinking or altered level of conscious-ness. Although individuals with delirium often have either hyperactivity or hypoactivity, this is not one of the criteria assessed on the CAM.

Answer to Question 2

ANS: B, C, D, E
Serving the resident finger foods and one dish at a time may improve the resident's intake at meals. Assigning a nursing assistant to sit with the resident may also accomplish the goal, as this may help in reducing environmental distractions. Because the resident can feed herself, it is im-portant to promote that level of independence for as long as possible. Assigning someone to feed the resident will impede her independence.