23.A Alzheimer's Disease
An inherited disease. Usually manifests before age 65 a. Early onset familial AD (eFAD) b. Sporadic AD (late-onset AD)
a. Early onset familial AD (eFAD)
Individuals with Alzheimer disease show a pattern of degenerative changes related to neuronal death throughout the brain. The cells die in a characteristic order. Place the following steps of neuronal death in order. 1. Neuronal death in the cerebral lobes produces a range of symptoms, including loss of remote memory and receptive aphasia. 2. Neurons in the limbic system including the hippocampus are damaged, resulting in emotional problems and loss of recent memory.
2, 1
Acetylcholinesterase inhibitors are often prescribed for the treatment of Alzheimers disease. They work by reducing acetylcholine breakdown. These drugs include donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne). About half of individuals who take these drugs see no delay in symptom progression. Which of the following are side effects seen with these medications? [SATA] a. Anorexia, nausea, diarrhea b. GI bleeding and bradycardia c. Headaches and dizziness d. Constipation e. Increased blood pressure
a, b, c
Which of the following are risk factors for AD? [SATA] a. Diabetes b. Cigarette smoking c. Moderate alcohol intake d. Heart-healthy diet e. Sedentary lifestyle
a, b, e
Which psychological factors should the nurse assess for in a client to determine the risk for development of Alzheimer disease (AD)? (Select all that apply.) A. Depression B. Schizophrenia C. Sleep disorders D. Bipolar disorder E. Elevated stress levels
A, C, E Rationale: Research shows a correlation between depression, sleep disorders, and elevated stress levels and the onset of Alzheimer disease. Schizophrenia and bipolar disorder do not lead to AD.
The home health nurse is caring for a client with a lower extremity venous stasis ulcer. Which clinical manifestations would lead the nurse to suspect the client has Alzheimer disease (AD)? (Select all that apply.) A. Looking for misplaced car keys B. Inability to tell time with a clock C. Evening and nighttime confusion D. Reporting the use of a day planner E. Taking walks up and down the street
A, B, C Rationale: Clients with AD may frequently lose items such as car keys and important items. They will also eventually lose the cognitive ability to tell time and be disoriented to place and time. Evening and nighttime confusion, called sundowning, is a frequent occurrence in clients with AD. Many people use a day planner or calendar to remember important appointments and events. Taking walks up and down the street is a form of exercise. As long as the client knows where he is and how to find his way home, this does not indicate AD.
A nurse is providing information about acetylcholinesterase inhibitors for the spouse of a client diagnosed with Alzheimer disease (AD). Which item will the nurse include in the teaching session? (Select all that apply.) A. Observe the client for improvement in manifestations. B. Notify the healthcare provider if manifestations worsen. C. The medication must be administered 1 hour before meals. D. Do not stop the medication without consulting the healthcare provider. E. Cholinesterase inhibitors will stop the progression of Alzheimer disease.
A, B, D Rationale: Appropriate teaching points to include are to not stop the medication without consulting with the healthcare provider, to observe for improvement, and to notify the healthcare provider if conditions worsen. The medication does not need to be administered 1 hour before a meal. The nurse would not include the teaching point that the medication will stop the progression of AD.
The nurse is providing teaching to a client recently diagnosed with Alzheimer disease. The client's daughter wants to know which services the Alzheimer Association offers. Which activity should the nurse include in the response? (Select all that apply.) A. Support B. Education C. Treatment D. Legal referrals E. Caregiver respite guidance
A, B, D, E Rationale: The Alzheimer Association provides education, support, legal referrals, and caregiver respite guidance. It does not provide direct treatment.
The family of a client with Alzheimer disease (AD) report that they can no longer manage the care in their home and are planning long-term care placement. Which information should the nurse provide the family to decrease the risk of relocation syndrome? (Select all that apply.) A. Bring pictures from home. B. Retain the same structure. C. Refrain from visiting for 12 weeks. D. Administer medication at different times. E. Use a daily schedule to remind the client of tasks.
A, B, E Rationale: Ways the nurse can help minimize the effects of relocation syndrome, which can occur when a client with AD is moved to another care facility, include bringing pictures from home and retaining as close to the same structure as possible. The client should be provided a daily schedule to remind the client of what happens at what time. Family should be encouraged to visit and be a part of the client's routine. Medications should be administered as they have been prescribed and not varied.
Which information should the nurse include when providing teaching at a community center about ways to prevent Alzheimer disease (AD)? (Select all that apply.) A. Consume a heart healthy diet. B. Refrain from consuming alcohol. C. Keep mentally active with puzzles. D. Get tested annually for Alzheimer disease. E. Take N-methyl-D-aspartate (NMDA) receptor antagonists.
A, C Rationale: Clients who are trying to prevent the onset of Alzheimer disease (AD) should consume a heart healthy (Mediterranean) diet because the foods in this diet have antioxidants and prevent the formation of amyloid plaques. Clients should keep mentally active by doing puzzles and playing games. It is believed that alcohol can be consumed in moderation to prevent AD. An individual should not routinely take NMDA receptor antagonists to prevent AD, and there is not a test that can be performed to diagnose AD.
A nurse on the medical-surgical unit has identified safety as a priority problem for a client who is in the late stages of Alzheimer disease (AD). The client is awake at night and tends to wander. Which priority intervention should the nurse use in the care of this client? (Select all that apply.) A. Keep a nightlight on in the room. B. Place a vest restraint on the client. C. Place nonskid slippers on the client. D. Keep the client's room free of clutter. E. Take the client to the bathroom every 2 hours.
A, C, D, E Rationale: Appropriate nursing interventions for this client to enhance safety include placing nonskid slippers on the client, keeping the client's room free of clutter, placing a nightlight in the client's room, and taking the client to the bathroom every 2 hours. Restraints are a last resort and should not be used unless absolutely necessary.
The nurse is teaching a group of adults at a health fair about modifiable risk factors for the onset of Alzheimer disease (AD). Which risk factor should the nurse include? (Select all that apply.) A. Obesity B. Hypertension C. Type 1 diabetes D. Sedentary lifestyle E. Traumatic brain injury
A, D Rationale: Modifiable risk factors are those that the client can control. This would include controlling weight (obesity) and increasing movement (sedentary lifestyle). Hypertension and type 1 diabetes can be controlled, but not eliminated. A traumatic brain injury cannot be modified.
The family of a client with Alzheimer disease (AD) reports the client is losing weight and having difficulty remembering how to use utensils. Which intervention should the nurse include in the plan of care for this client? (Select all that apply.) A. Use finger foods. B. Initiate tube feedings. C. Begin total parenteral nutrition. D. Refer the client to a registered dietician. E. Provide liquid supplements such as Ensure or Boost.
A, D, E Rationale: The client with AD may eventually forget how to use utensils for eating and begin to lose weight. Appropriate interventions for the nurse to include would be to incorporate finger foods into the diet. A registered dietician would be able to develop a meal plan for the client. Liquid supplements such as Ensure or Boost would provide a concentrated source of calories and can be used without utensils.
A client has been diagnosed with stage 1 Alzheimer disease (AD). Which activity should the nurse describe as helpful for the client when meeting with the spouse? A. Writing reminders for appointments B. Doing a crossword puzzle each day C. Interacting in group activities D. Driving a car locally
A. Writing reminders for appointments Rationale: A person with stage 1 AD may need to use assistive devices such as calendars and written instructions to remember important events and appointments. Driving may be dangerous depending on the client's mental status. Group activities may be overwhelming for a client with AD and can increase confusion and combativeness. Doing a daily crossword puzzle can stimulate the mind, slowing the progression of AD.
Which statement by a family member of a client with Alzheimer disease (AD) indicates an understanding of the disease? A. "Clients with AD can only be definitively diagnosed with an autopsy." B. Clients with AD show rapid improvement in mental status with medication." C. "Clients with AD frequently have sexually transmitted infections." D. "Clients with AD have remissions and exacerbations of the disease."
A. "Clients with AD can only be definitively diagnosed with an autopsy." Rationale: Due to the neurofibrillary tangles, amyloid plaques can only be noted during an autopsy. Therefore, AD can only be diagnosed with an autopsy. Sexually transmitted infections can be a cause of delirium and confusion, but they do not cause AD. AD is a progressive deterioration of mental status. The client does not experience remissions and exacerbations. Medication will slow the progression of the disease but does not produce a rapid improvement in mental status.
The nurse is caring for a client with stage 2 moderate Alzheimer disease. Which collaborative colleague in healthcare should the nurse anticipate working with for optimal care of this client? (Select all that apply.) A. Hospice B. Dietitian C. Speech therapist D. Physical therapist E. Occupational therapist
B, C, D, E Rationale: In moderate Alzheimer disease, it is appropriate for the client to receive physical therapy, occupational therapy, speech therapy, and guidance from the dietitian. Hospice is applicable in stage 3 severe Alzheimer disease.
The nurse is discussing the care of a client with Alzheimer disease (AD) with the family. The family reports the client has frequent mood swings and becomes combative. Which intervention should the nurse expect the healthcare provider to prescribe? A. Implement behavioral interventions. B. Administer selective serotonin reuptake inhibitor (SSRI) antidepressants. C. Increase acetylcholinesterase inhibitor dose. D. Utilize physical and chemical restraints.
B. Administer selective serotonin reuptake inhibitor (SSRI) antidepressants. Rationale: Clients with AD will experience frequent mood swings and may become combative. Research shows success in decreasing mood swings with the use of SSRI antidepressants. Increasing the acetylcholinesterase inhibitor dose will not change the client's mood. Behavioral interventions may be effective, but do not last long. Physical and chemical restraints should be a last resort.
The nurse working in a long-term care facility develops a plan of care for a client with stage 2 Alzheimer disease (AD) and a nursing diagnosis of Memory, Impaired. The client becomes agitated easily. Which intervention would be appropriate for the nurse to include? A. Challenge the client's responses. B. Ask the client one question at a time. C. Avoid making eye contact. D. Speak in a loud monosyllabic tone.
B. Ask the client one question at a time. Rationale: When communicating with the client who has impaired memory, it is best to ask only one question at a time and preferably yes or no questions. The nurse should make eye contact with the client, but never challenge the client's responses because this can increase agitation. The nurse should speak in a calm and reassuring tone so as to not frighten the client. (NANDA-I ©2014)
The nurse is caring for a client with stage 3 Alzheimer disease (AD) who has become bedridden and requires 24-hour care. The family is exhausted and requests assistance. Which intervention would the nurse suggest? A. Antipsychotic medication B. Respite care C. Acetylcholinesterase inhibitor D. Hospice services
B. Respite care Rationale: Respite care is important for the family of a client with AD because the care is exhausting and demanding. Respite care can provide the family a short break to refresh and take care of themselves. Hospice services are for clients with a terminal illness. Hospice may eventually be beneficial for this client and family, but there is no information that the client meets hospice criteria yet. An acetylcholinesterase (AChE) inhibitor is used to slow the disease progression. This client is in the third and final stage of AD and would likely not derive benefit from this medication. Antipsychotic medication can help calm the client but does not provide relief from the demands of 24-hour client care. A healthcare provider must prescribe medications.
The nurse is working with a client newly diagnosed with Alzheimer disease (AD). The family member asks about the cause of this disease. Which statement explains the etiology of AD to the family member? A. "Alzheimer disease can be caused by infections, new medications, and cardiopulmonary diseases." B. "Many theories exist about the cause of AD. One theory is the brain cannot process a specific protein." C. "Most cases of AD have a genetic basis. These are considered familial and happen to older adults." D. "Do not worry. Your chances of acquiring the disease are minimal since the genetic mutation skips a generation."
B. "Many theories exist about the cause of AD. One theory is the brain cannot process a specific protein." Rationale: Many theories do exist about the cause of AD. This includes the cholinergic, amyloid, and tau hypotheses. The amyloid hypothesis is the most accepted one at this point and is based on the brain being unable to process a certain protein called amyloid precursor protein. Familial AD occurs in younger, not older, adults. Infections, new medications, and cardiopulmonary diseases can cause delirium or temporary confusion, not AD. There is no evidence that AD skips a generation.
A client with a family history of Alzheimer disease (AD) asks the nurse how to decrease the risk of developing the disease. How should the nurse respond? A. "You cannot decrease your risk because this disease is in your genetics." B. "You can take over-the-counter gingko biloba to improve memory." C. "You should maintain a healthy lifestyle with diet and exercise." D. "You should decrease intake of alcoholic beverages to decrease the risk."
C. "You should maintain a healthy lifestyle with diet and exercise." Rationale: The best way to decrease this person's risk for acquiring AD is to maintain a healthy lifestyle. This includes diet and exercise. The nurse would not inform the client there is no way to decrease the risk of developing AD since it runs in the family because this is inaccurate. Over-the-counter herbal supplements such as gingko biloba and other complementary health approaches have not been proven to help slow the onset of AD. Moderate alcohol consumption is appropriate to decrease the risk.
The nurse is working with a client who presents with confusion, losing important items, and inappropriate behavior. Which assessment should the nurse anticipate to assist with diagnosis of Alzheimer disease (AD)? (Select all that apply.) A. Borg scale B. Braden scale C. SF-36 health survey D. Presence of dementia E. Mental status examination
D, E Rationale: The presence of dementia, a mental status examination, and the Alzheimer Disease Assessment Scale are used to diagnose AD. The Borg scale is used to measure perceived exertion during exercise. The SF-36 health survey, a measure of health status and quality of life, is not used to diagnose AD. The Braden scale is used to assess the risk for developing a pressure ulcer.
The nurse is caring for a client with stage 2 Alzheimer disease (AD) who is unable to remember how to get dressed. Which nursing intervention would assist the client to maintain independence? A. Give the client pictures of each step to follow. B. Play a video of a person dressing herself. C. Provide assistance with each step of dressing. D. Tell the client each step and allow her to perform it.
D. Tell the client each step and allow her to perform it. Rationale: To maintain independence as much as possible, the nurse should tell the client each step to perform and allow the client to do the task. Playing a video or giving the client pictures may be overwhelming. Providing assistance with each step promotes dependence.
The nurse is teaching a group of unlicensed assistive personnel (UAPs) about caring for clients with Alzheimer disease (AD). Which statement by a UAP provides an accurate description of AD? A. "Alzheimer disease is a temporary state of mental confusion and fluctuating consciousness." B. "Alzheimer disease is an exaggerated feeling of physical and mental well-being." C. "Alzheimer disease involves dyskinetic movements from disordered tonicity of muscles." D. "Alzheimer disease is a progressive deterioration of brain function."
D. "Alzheimer disease is a progressive deterioration of brain function." Rationale: Alzheimer disease is a type of dementia that causes progressive deterioration of brain function. Euphoria is an exaggerated feeling of physical and mental well-being. Dystonia describes dyskinetic movements caused by disordered tonicity of muscle. Delirium is a temporary state of mental confusion and fluctuating consciousness.
A structured approach to orienting individuals to person, time, place, and situations at regular intervals and as needed through verbal communication and the use of visual cues. A collaborative intervention that is carried out by all members of the healthcare team. a. Reality orientation b. Validation therapy c. Reminiscence therapy
a. Reality orientation
Shows no clear pattern of inheritance, although genetic factors may increase risk. Develops after age 65. More common than other type, accounting for 95% or more of all cases. a. Early onset familial AD (eFAD) b. Sporadic AD (late-onset AD)
b. Sporadic AD (late-onset AD)
Involves searching for emotion or intended meaning in verbal expressions and behaviors. The basic premise is that seemingly purposeless behaviors and incoherent speech have significance to the patient and can be related to current needs. a. Reality orientation b. Validation therapy c. Reminiscence therapy
b. Validation therapy
Uses the process of purposely reflecting on past events. Nurse or healthcare provider may encourage the patient to talk about events that occurred in the past, often by using scrapbooks, photo albums, music, or other items to facilitate the process. May be comforting and provide a source of self esteem for the client. a. Reality orientation b. Validation therapy c. Reminiscence therapy
c. Reminiscence therapy
Which of the following is the most prominent risk factor for Alzheimer disease? a. Hispanic/African American b. Family history of AD c. Being female d. Advancing age
d. Advancing age All of the other options are risk factors for AD, but advancing age is the most prominent. Risk for AD doubles every 5 years following age 65. After 85, there is a 50% risk of developing the disease.
Memantine, an NMDA receptor antagonist, is often used to treat Alzheimers disease. It works by blocking the effects of glutamate, a neurotransmitter that is present with neuronal damage and appears to be involved in cognitive decline. It does not reverse existing damage, but does slow the rate at which new damage occurs. Which of the following would be appropriate for the nurse to consider regarding this medication? a. Monitor for GI bleeding b. Use sunscreen when going outdoors c. Monitor pulse rate prior to administration d. Take this medication with food if stomach upset occurs
d. Take this medication with food if stomach upset occurs A and C are considerations for Acetylcholinesterase inhibitors such as donepezil, rivastigmine, and galantamine