ATI Video Neurocognitive Disorders
A nurse is teaching about home safety with the adult daughter of a client who has Alzheimer's disease and has recently started wandering aren't the house at night. Which of the following statements by the daughter indicates an understanding of the teaching?
"I will have new locks installed at the tops of our outside doors." Installation of complex locks or locks placed at the tops of doors can prevent clients from wandering outside. In moderate to late stages of dementia, the ability to look and reach upward is lost.
A nurse is walking in the hallway with a client who has dementia. The client says, "I just saw the little white dog my father gave me when I was 10! Go get him for me." Which of the following replies by the nurse illustrates the use of validation therapy?
"You must have loved your dog. Tell me about him." This reply demonstrates validation therapy because the nurse replies to misperceptions verbalized by the client about her earlier life or environment by demonstrating interest in the client's life and asking the client to reminisce about the topic. Validation therapy calms and redirects the client rather than increasing anxiety and agitation.
A nurse is providing discharge teaching with the caregiver of a client who has Alzheimer's disease and has a new prescription for memantine. Which of the following instructions should the nurse include in the teaching?
Provide extra assistance during ambulation to prevent falls. Dizziness, especially at the beginning of therapy, is a common adverse effect of memantine and can affect the client's balance. The caregiver should take extra care to prevent falls, such as providing assistance with ambulation.
A charge nurse in a long-term facility is planning care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the care plan?
Stay within two arm lengths of the client when talking to her. Staying one to two arm lengths from the client and facing her when talking to her facilitates personal communication and helps the client focus on what the nurse is saying without invading her personal space.
A nurse is admitting an older adult client who fell at home and is disoriented by time, place, and person. Which of the following findings should indicate to the nurse that the client is experiencing delirium?
The client is experiencing rapid mood swings. The presence of rapid mood swings and fluctuations in mood and behavior should alert the nurse to the presence of delirium in this client. Causes of delirium can include medical conditions such as infection, acute alcohol withdrawal, and postoperative complications.
