Alzheimer's Disease (Advanced Stages) HESI Case Study

Meet the Client

During a routine physical exam, a client states that she has become increasingly forgetful and worries that old age is catching up with her. The nurse notes that the client has difficulty finishing some of her sentences because she forgets common words and that she is wearing only a thin sweater on a very cold day. The client is scheduled for more in-depth evaluation for possible neurocognitive disorder due to Alzheimer's disease.

Warning Signs & Risk Factors

Early indicators from the mental status exam show that the client has impaired cognitive functioning. The nurse explains to the client and her spouse that a number of different problems can result in altered cognition. The nurse discusses early warning signs and risk factors for Alzheimer's disease with the couple. The client's spouse says that the client does not like herself anymore.

Diagnostic Studies

The client is scheduled for lab work and neuroimaging tests, including a magnetic resonance imaging (MRI) and a positron emission tomography (PET). The client's spouse asks the nurse what these tests will show.

Caregiver Role Strain

The nurse recognizes that the spouse is experiencing caregiver role strain and develops a plan of care for him with the RN team leader.

Disease Progression

The spouse calls the nurse some time later and reports that the client's behavior is deteriorating more quickly than he was expecting. He states, that it's only been 2 years since all this started and he thought this disease progressed very slow. The spouse wants to know if he is doing something wrong.

Therapeutic Communication: Grief

The spouse cares for the client in their home with the help of the home health care team until her Alzheimer's disease progresses to the point at which she is completely bedridden and is no longer able to perform any self-care measures. The spouse notifies the nurse that he plans to place the client in a long-term care facility. While speaking with the nurse, the spouse says that he thinks she would be better off if she died, but feels so guilty for even thinking that.

Adult Day Care

The spouse takes the client to the adult care center 3 days a week, where she watches old movies, participates in activities, and eats lunch with other clients with Alzheimer's disease.

Case Outcome

The spouse visits the client in the long-term care facility until her death 2 years later. He continues to work with the support group to assist other caregivers experiencing the strain of caring for loved ones with Alzheimer's disease.

The nurse provides teaching to the spouse to help reduce the client's urinary incontinence. Which actions are most important for the spouse to initiate? (Select all that apply.) a. Keep a commode at the bedside. b. Keep a bell handy for the client to ring when she needs to void. c. Take the client to the bathroom every 2 hours. d. Ask the client if she needs to use the bathroom after meals. e. Establish a toileting schedule at the same time daily.

a. Keep a commode at the bedside. This may be useful in establishing a routine to promote continence, and it will provide easy access for nocturia. c. Take the client to the bathroom every 2 hours. Continence may be promoted if the client with Alzheimer's disease is taken to the bathroom on a regular schedule of at least every 2 hours during the day. d. Ask the client if she needs to use the bathroom after meals. This may be useful because it is likely to help establish a pattern that promotes continence. e. Establish a toileting schedule at the same time daily. This is a useful way to promote continence; toileting at the time of arising in the morning, after meals, and before bedtime is a good way to establishing this schedule.

Which technique is most useful in helping a client with Alzheimer's disease recognize the bathroom? a. Place a picture of a toilet on the bathroom door. b. Place a sign that says "bathroom" on the bathroom door. c. Place a colored flag on the bathroom door. d. Place a colored strip of tape at the bathroom entrance.

a. Place a picture of a toilet on the bathroom door. Picture recognition is a useful tool in helping the client with Alzheimer's disease locate the bathroom.

What option provides the best respite for the spouse? a. Hospice Care for the client b. Adult Day Care for the client. c. Meals on Wheels Service for both the spouse and client d. A visiting nurse to assess the client's status

b. Adult day care for the client. While the client is still ambulatory, she can spend several hours a day at an adult day care facility, which would provide the spouse with respite from the constant demands of caring for the client.

What action should the nurse implement? a. Confront the client about his disruptive behavior. b. Re-orient the client to scheduled meal times. c. Provide a snack that the client can eat. d. Reassure the client that he has just eaten.

c. Provide a snack that the client can eat. Responding to the client's reality is referred to as validation therapy and is a useful intervention to reduce client agitation, especially in the later stages of Alzheimer's disease.

After the nurse assists the client back to the bed, which nursing action has the highest priority? a. Administer oxygen per nasal cannula. b. Notify the healthcare provider of the vital signs. c. Provide several warm blankets. d. Educate unlicensed staff about the need for client to rise slowly and ensure close monitoring/frequent rounding.

d. Educate unlicensed staff about the need for client to rise slowly and ensure close monitoring/frequent rounding. The client is experiencing postural hypotension secondary to her initial dose of the anti-anxiety medication. The priority nursing action is to provide patient safety. Postural hypotension is a common side effect that occurs when a client, who is taking anti-anxiety medication, stands up too quickly from a lying or sitting position.

Which response is best for the nurse to provide? a. Tell the spouse most people would feel guilty for thinking that too. b. Ask the spouse why he feels she would be better off. c. Remind the spouse that he is likely too tired to think clearly. d. Instruct the spouse that he is having many conflicting emotions right now.

d. Instruct the spouse that he is having many conflicting emotions right now. This response restates the spouse's feelings and provides the opportunity for him to continue to share his concerns.

Leadership Aspects

The next morning, the client is scheduled to go home. The nurse administers the client's last dose of IV antibiotic and plans to remove the IV. The client indicates by her behavior that the IV site is painful.

Cognitive Function Assessment

The nurse administers a mental status examination to assess the client's cognitive function. The client's spouse is present during the exam.

This exam included which component? a. appetite b. judgement c. pupillary response d. babinski's reflex

b. Judgement Evaluation of cognitive function includes assessment of attention, concentration, judgment, perception, learning, memory, communication, language, and speed of processing information.

Medication Therapy

Since the lab test results are normal, and neuroimaging tests are consistent with Alzheimer's disease, the nurse and RN team leader develop a plan of care for the client and her spouse that is consistent with the medical diagnosis of Alzheimer's disease. The client receives prescriptions for trazodone and donepezil.

Distorted Thought Processes

The PN and RN team leader identify "distorted thought processes" as a priority problem for the client. Focusing on this problem, the nurse provides client teaching to the client's spouse. The nurse instructs the spouse about measures to promote cognitive restructuring.

Oxazepam 15 mg tablet by mouth (PO) as needed (PRN) for anxiety every 4 hours is ordered. Oxazepam 30 mg is available in the automatic medication dispenser. How many tablet(s) of oxazepam should the nurse administer to the client? (Enter numerical value only. If rounding is necessary, round to the nearest tenth.)

0.5 D/H x V = X15/30 x 1 = 0.5 or ½ tablet 15mg (prescribed dose) / 30 mg (on hand or available supply) = 0.5 or 1/2

Ethical-Legal Considerations: Use of Restraints

The client becomes agitated at home and the home health nurse notes that the client's temperature is elevated. The client's spouse takes the client to the HCP where she is diagnosed with urosepsis. The client is admitted to the hospital for IV antibiotics. By the second day of hospitalization, the client's behavior becomes increasingly agitated. While the nurse is administering a dose of antibiotics, the client attempts to climb out of bed and demonstrates hostile, belligerent behavior toward the nurse.

A Complication Occurs

The nurse is able to redirect the client's attention and reduce her agitation. However, throughout the day, the client continues to wander in her room, the hallway, and the family room on the nursing unit, and she experiences occasional episodes of agitation and anxiety. Later, another nurse prepares to administer a dose of oxazepam to the client, by scanning the barcode on the medication for proper client and medication identification.

Which understanding by the nurse regarding Alzheimer's disease is accurate? a. Changes in behavior and personality often occur in early Alzheimer's disease. b. Behavior changes may indicate that she has already progressed to a later stage of the disease. c. Behavior changes are probably the result of her effort to cope with her altered mental function. d. Behavior changes usually indicate that the person is feeling depressed about the situation.

a. Changes in behavior and personality often occur in early Alzheimer's disease. Subtle changes in behavior and personality, which would easily be recognized by a loved one, occur even in early Alzheimer's disease.

What action should the nurse take? a. Evaluate the client's vital signs before transferring her to her bed. b. Monitor the client's blood glucose level after she is back in her bed. c. Assist with transferring the client to her bed and turn on a night light. d. Advise the UAP to turn off the room light and to let the client rest in the chair.

a. Evaluate the client's vital signs before transferring her to her bed. The client may be experiencing an adverse effect of the medication, and she should be assessed before further action is initiated.

The client's spouse asks the nurse what are typical behaviors for early stage Alzheimer's disease. Which nursing explanation best promotes effective communication? a. Frequently misplacing the keys to the car b. Needs assistance choosing clothes appropriate for season c. Wandering off and losing perspective of location d. Requiring assistance with dressing

a. Frequently misplacing the keys to the car Losing or misplacing valuable objects is seen in early-stage Alzheimer's disease. The client is still able to function independently.

How should the nurse explain the therapeutic effect of Donepezil to the couple? a. Improves thinking and functioning abilities b. Restores destroyed cells c. Decreases hallucinations and delusions d. Reduces periods of depression

a. Improves thinking and functioning abilities Donepezil, classified as an acetylcholinesterase inhibitor, is used in Alzheimer's disease to delay the onset of cognitive decline.

When the nurse is conducting the client's cognitive function, which components of the mental status exam best assesses the client's cognition? (Select all that apply. One, some, or all options may be correct.) a. LOC b. level of eye contact c. remote memory d. speech articulation e. facial expression

a. LOC Level of consciousness is an assessment of the client's congition. c. remote memory Remote memory is an assessment of the client's congition.

Which task can the assigned PN carry out? (Select all that apply. One, some, or all options may be correct.) a. Observe the IV site for phlebitis while discontinuing the IV. b. Teach the spouse about the oral antibiotic the client will take at home. c. Communicate with the social worker regarding the client's discharge needs. d. Administer the first scheduled dose of the prescribed oral antibiotic. e. Calculate the client's intake and output for the shift.

a. Observe the IV site for phlebitis while discontinuing the IV. A PN can do a focused assessment on an IV site and monitor for complications. b. Teach the spouse about the oral antibiotic the client will take at home. A PN is able to instruct their clients on medications per their scope of practice. d. Administer the first scheduled dose of the prescribed oral antibiotic. This action is within the scope of practice of the PN. e. Calculate the client's intake and output for the shift. This action is within the scope of practice of the PN.

To promote the well-being of a group of clients with Alzheimer's disease, which goals are important for the nurse manager of an adult care center to include in the plan of care? (Select all that apply. One, some, or all options may be correct. a. Provide forms of moderate sensory stimulation. b. Ensure opportunities for physical activity. c. Maintain a calm, consistent environment. d. Encourage games that include high energy levels. e. Incorporate pet therapy.

a. Provide forms of moderate sensory stimulation. Music and art therapy, as well as other forms of sensory stimulation, may be a part of the care for clients with Alzheimer's disease, but it is essential to avoid over-stimulation to reduce confusion. b. Ensure opportunities for physical activity. Promoting physical mobility is an important goal. c. Maintain a calm, consistent environment. To reduce confusion and maintain function as long as possible, it is most important that the nurse control the environment of clients with Alzheimer's disease. Control of the environment will prevent over-stimulation and will ensure a consistent routine. Both are essential to managing the behavior of clients with Alzheimer's disease who are easily agitated. e. Incorporate pet therapy. Pet therapy is another form of sensory stimulation that may calm clients with Alzheimer's disease.

The nurse is concerned that the client will develop sundowning syndrome. Which instructions should be included when teaching the spouse some appropriate measures to reduce this problem? (Select all that apply. One, some, or all options may be correct.) a. Provide the client with a relaxing backrub at bedtime. b. Keep some light on in the bedroom at night. c. Eliminate client's fluid intake after the evening meal. d. Increase toileting to every hour from supper until bedtime. e. Provide a calm atmosphere during the day.

a. Provide the client with a relaxing backrub at bedtime. Touch, as well as other relaxation techniques, is useful in reducing the nocturnal confusion referred to as sundowning syndrome. b. Keep some light on in the bedroom at night. Maintaining some light in the room after dark is useful in reducing the nocturnal confusion referred to as sundowning syndrome. e. Provide a calm atmosphere during the day. A calm atmosphere during the day is useful in reducing the nocturnal confusion referred to as sundowning syndrome.

What action should the nurse implement first? a. Redirect the client's attention to holding a stuffed animal. b. Quietly leave the room until the client calms down c. Assign an unlicensed assistive personnel (UAP) to remain with client. d. Apply a soft vest restraint and bed alarm.

a. Redirect the client's attention to holding a stuffed animal. The nurse should first attempt to calm the client by redirecting her attention or distracting her from the source of the anxiety.

Which information indicates possible serious side effects of trazodone? (Select all that apply. One, some, or all options may be correct.) a. The client is taking MAOIs. b. The client is complaining of dizziness upon standing. c. The client has urinary urgency. d. The client has a history of depression. d. The client has a history of cardiac disease.

a. The client is taking MAOIs. MAOIs and trazodone are antidepressants that cannot be used in conjunction with each other. There must be a 2-week period without MAOIs before trazadone is administered. b. The client is complaining of dizziness upon standing. Orthostatic hypotention can cause dizziness and potential for falls and injury. d. The client has a history of cardiac disease. Trazadone may exacerbate coronary problems, and the HCP needs to know this history prior to prescribing trazadone.

What are appropriate responses by the nurse? (Select all that apply.) a. The client needs to be calmed down immediately. She is upsetting her husband. b. The medication will prevent the client from harming herself. c. A medication may not be needed if distraction is effective. d. Refuse to allow the charge nurse to give an unneeded medication. e. The client says her hip hurts and she has an order for pain medication.

a. The client needs to be calmed down immediately. She is upsetting her husband. The use of an antianxiety medication, such as oxazepam, represents an appropriate medication when used as prescribed to manage anxiety that is manifested as agitation, especially if the behavior is unsafe, like pulling out the IV line. Chemical restraints, usually antipsychotics, are drugs given for the specific purpose of inhibiting a certain behavior or movement. b. The medication will prevent the client from harming herself. The use of an antianxiety medication prescribed for anxious and agitated behavior in the client with Alzheimer's disease represents an appropriate medication, when used as prescribed to manage unsafe behavior, like pulling out the IV line. Chemical restraints, usually antipsychotics, are drugs given for the specific purpose of inhibiting a certain behavior or movement. c. A medication may not be needed to if distraction is effective. This is an assertive response that promotes client advocacy and prevents unnecessary chemical restraint. e. The client says her hip hurts and she has an order for pain medication. Assessing the client's complaint of pain is appropriate because clients with Alzheimer's disease may not be able to ask for pain medication. Administering the appropriate prescribed pain medication may alleviate the client's pain and diminish her anxiety and agitation. Administering appropriate prescribed medication based on an assessment of the client's overall condition or symptoms, for example, sleeping medication for insomnia, antianxiety medication to calm an anxious client, or analgesics for pain management, is not considered a chemical restraint.

Which information indicates the Trazodone is have the desired effect? a. The client sleeps through the night. b. The client is able to control her bladder at all times. c. The client often wanders around through the house. d. The client denies feeling any pain.

a. The client sleeps through the night. Trazodone is an antidepressant often used to improve sleep in the client with Alzheimer's disease.

The nurse's response should be based on which understanding about Alzheimer's disease? a. Alzheimer's disease is a rapidly progressing disease, with deterioration that results in a typical lifespan of 2 to 5 years. b. Alzheimer's disease is a chronic disease that can progress with no set sequence and that has a typical lifespan of 1 to 15 years with the average being 4-8 years. c. Alzheimer's disease is a chronic, progressive disease with a clearly defined course and a typical lifespan of 20 to 30 years. d. Alzheimer's disease is a chronic disease that stabilizes after an initial rapid deterioration and has no defined lifespan.

b. Alzheimer's disease is a chronic disease that can progress with no set sequence and that has a typical lifespan of 1 to 15 years with the average being 4-8 years. This most correctly describes the course of Alzheimer's disease.

Which questions are most important to ask the spouse before developing the plan of care? (Select all that apply. One, some, or all options may be correct.) a. Ask how their children are coping with their mother's disease. b. Have the spouse say what he finds most stressful in his daily life. c. Inquire about any participation with a caregiver support group. d. Evaluate how much time the spouse spends taking care of himself. e. Find out what activities the spouse attends outside of the home.

b. Have the spouse say what he finds most stressful in his daily life. This question will elicit information concerning the caregiver's perceptions about the stress in his life, which is the most important information for the nurse to obtain. c. Inquire about any participation with a caregiver support group. This will provide useful information for what resources are currently being used. d. Evaluate how much time the spouse spends taking care of himself. This will provide useful information on the extent of caregiver support the spouse will need. e. Find out what activities the spouse attends outside of the home. This will provide useful information that will help in the nurse's discussion with the spouse. The nurse will need to discuss the activities with the spouse to ascertain whether these activities are providing respite for him. For example, is he visiting with friends for a couple of hours or is he going to the pharmacy or grocery shopping? The latter are task-oriented and do not provide respite.

Which is the best response by the nurse? a. Instruct the spouse to correct the clients in accurate statements and promote reality orientation. b. Reinforce that it is right to balance the clients feelings with the need to promote reality. c. Tell the spouse that the client is attempting to manipulate him and make sure she gets her own way. d. Share with the spouse that there is no reason to attempt to correct the client because she will not understand.

b. Reinforce that it is right to balance the clients feelings with the need to promote reality. Reality orientation is an important tool for the client with early-stage Alzheimer's disease; however, as the disease progresses, reality orientation often causes the client to become agitated. It is important to recognize the feelings and emotions of the client with Alzheimer's disease.

The spouse begins to cry. What initial intervention should the nurse implement? a. Quietly leave the room until the spouse is in control of his emotions. b. Remain seated next to the spouse while he is crying. c. Reassure the spouse that he is taking the best action. d. Encourage the spouse to share his feelings at his support group.

b. Remain seated next to the spouse while he is crying. The nurse should remain with the spouse and allow him to cry and then offer additional support and options.

What is the best explanation by the nurse? a. The tests are only used to help rule out other causes for the clients symptoms since there are no tests that can be used to diagnose Alzheimer's disease. b. The healthcare provider is looking for changes in the brain that are consistent with Alzheimer's disease or for other conditions that can cause the client's symptoms. c. The tests will provide information about the staging of the Alzheimer's disease, so the healthcare provider will know which medications to prescribe for the best treatment. d. The imaging test results will be used to analyze the effectiveness of the treatment protocol used to shrink the diseased brain tissue.

b. The healthcare provider is looking for changes in the brain that are consistent with Alzheimer's disease or for other conditions that can cause the client's symptoms. Although there are no diagnostic tests that provide a definitive differential diagnosis of Alzheimer's disease, several imaging tests provide data that show changes consistent with AD. Other problems that cause dementia may also be found via neuroimaging tests.

Which member of the home care team should be assigned to revise the client's plan of care to reflect her changing condition? a. The nurse manager of the home health agency. b. The home health RN who visits every other week. c. The home health PN who visits twice a week. d. The home health aide who visits three times a week.

b. The home health RN who visits every other week. Revision of the plan of care is best performed by the RN who visits the client. It should be based on the nurse's assessment, as well as reports and collaboration with the PN and home health aide.

What is the best response by the nurse? a. "She is showing signs of late-stage disease and she will soon stabilize at her current level of functioning." b. "Esther's healthcare provider will explain the expected disease progression at your next appointment." c. "Every person responds differently to the disease, but it is likely that her ability to function will continue to decline." d. "It is important to maintain a positive attitude and to not worry too much about what will happen next."

c. "Every person responds differently to the disease, but it is likely that her ability to function will continue to decline." This response provides accurate information and an opportunity for further client teaching and emotional support.

Which intervention should the nurse include in the client and family teaching? a. Play classical music every day at the same time. b. Provide Esther with a journal to record her thoughts. c. Help Esther recognize the strong emotions that she is feeling. d. Remove family items that may cause Esther to dwell in the past.

c. Help Esther recognize the strong emotions that she is feeling. The goal of cognitive restructuring in the client with early-stage Alzheimer's disease is to challenge the client to alter distorted thought patterns and view the world more realistically. One technique is to help the client recognize emotions such as anger, fear, and anxiety.

Which nursing intervention is best when interviewing the client and her spouse to elicit information about possible risk factors for Alzheimer's disease? a. Ask if there is a family history of depression or manic behavior. b. Ask if the client has a history of any thyroid gland problems. c. Ask if the client has a history of a stroke or transient ischemic attacks. d. Ask if there is any family history of Alzheimer's disease.

d. Ask if there is any family history of Alzheimer's disease. There seems to be a genetic predisposition to the development of Alzheimer's disease for many individuals. Genetic testing may be useful for the differential diagnosis because four genes are currently associated with the disease. In addition, information about previous head trauma, exposure to toxic or metal waste, or any viral illnesses should be elicited when the nurse obtains Esther's history.

How should the nurse facilitator respond to this participant's joking behavior? a. Confront the man about this inappropriate behavior. b. Help the man recognize the need to approach his responsibilities seriously. c. Ask the other members of the group to ignore the man's behavior. d. Encourage all group members to use humor as a coping mechanism.

d. Encourage all group members to use humor as a coping mechanism. Humor can serve as an effective coping mechanism for the caregiver of a client with Alzheimer's disease.

How should the nurse explain the lab information to the client's spouse? a. The results likely indicate that the disease is in the early stages. b. It is common for test results to change as the disease progresses. c. Normal laboratory tests are not typical and may need to be repeated. d. Normal laboratory test results help rule out other causes for the symptoms.

d. Normal laboratory test results help rule out other causes for the symptoms. There are many causes of dementia, especially in the older client. Laboratory tests help rule out treatable causes before a diagnosis of Alzheimer's disease is established.

How should the nurse respond? a. Explain that it is a good idea to wait because the client's condition will worsen, and she will develop a tolerance to the medication's effect. b. Tell the spouse that it may be beneficial to wait and not to start the medication until the her healthcare provider is available to ask. c. Inform the spouse that this medication has many side effects, and it should be taken early in the disease while the client is still physically strong. d. Reinforce that this medication provides the most benefit to persons with early-stage Alzheimer's disease, so it is important to start it right away.

d. Reinforce that this medication provides the most benefit to persons with early-stage Alzheimer's disease, so it is important to start it right away. Acetylcholinesterase inhibitors, such as donepezil, are most useful in stabilizing cognitive decline in early-stage Alzheimer's disease.

Which side effect should the nurse instruct the spouse to report immediately? a. incontinence b. insomnia c. muscle cramps d. dizziness

d. dizziness Dizziness may be a predictor of a serious side effect of syncope and should be reported immediately.