Edapt - Dementia
Understanding that Lorena's condition is consistent with delirium, which response by the nurse is most appropriate? "Alzheimer's disease is progressive, so there is nothing that will make her better." "A prescription for memantine may help reverse the damage in your mother's brain." "An antipsychotic drug will be very helpful when your mother gets agitated." "Adding an antidepressant to your mother's medication schedule may help her sleep better."
"Adding an antidepressant to your mother's medication schedule may help her sleep better."
Based on the conversation with Elizabeth and observations of Lorena, which actions should the nurse recommend to Elizabeth to help decrease her mother's sundowning symptoms? Select all that apply. "Find time to sit quietly in a calm environment with Lorena around the late afternoon." "That is called sundowning, which is a symptom of your mother's disease. There is nothing you can do to help." "Try to open blinds and turn on lights during the day to increase Lorena's exposure to daylight." "Work on limiting the amount of caffeine that Lorena has in the afternoon." "Allow Lorena to sit alone in her room quietly during the daytime for a nap."
"Find time to sit quietly in a calm environment with Lorena around the late afternoon." "Try to open blinds and turn on lights during the day to increase Lorena's exposure to daylight." "Work on limiting the amount of caffeine that Lorena has in the afternoon."
After a thorough examination and diagnostic evaluation, Lorena has been diagnosed with Alzheimer's disease (AD). Which statement, made by Lorena, shows the nurse that Lorena understands her disease process? "My family should get tested immediately to see if they have Alzheimer's disease, too." "If I had not smoked so much growing up, this wouldn't be a problem." "Hopefully with some therapy, I can get better." "I should make arrangements about my medical decisions and advanced directives now."
"I should make arrangements about my medical decisions and advanced directives now."
Which of the following statements that Elizabeth expressed can help the nurse determines that Elizabeth understand measures to keep Lorena safe? Select all that apply. "I will make sure Mom is wearing closed-toed shoes when walking." "I will make sure all handrails are secure." "Mom will not be able to shower or use a bathtub." "I will make sure the stairwells do not have bright lights, so Mom does not get dizzy when walking." "It is a good idea to remove any throw or area rugs and extension cords off the floor."
"I will make sure Mom is wearing closed-toed shoes when walking." "I will make sure all handrails are secure." "It is a good idea to remove any throw or area rugs and extension cords off the floor."
"I asked Lorena what time it was, and she was not able to recognize the numbers on a clock." Problems with Abstract Thinking "Lorena made the best chili for the last 40 years, but now she doesn't seem to remember how to cook it." Difficulty doing familiar tasks "I went to pick up Lorena to come to the doctor's office, and she was wearing her ski pants. It's 90 degrees outside." Poor or decreased judgment "I was at Lorena's house earlier and the phone was ringing, but she couldn't tell me that is what the sound was. It was like she forgot the word phone." Problems with Language "Lorena was very flustered this morning because she could not find her glasses. Well, I found them in the freezer. She didn't remember putting them there." Misplacing things
1. Problems w/abstract thinking 2. Difficulty doing familiar tasks 3. Poor or decreased judgement 4. Problems w/language 5. Misplacing things
Which statement best describes "sundowning"? Being unable to remain awake after the sun sets A normal symptom of the aging adult A manifestation of delirium A specific type of agitation found in dementia clients
A specific type of agitation found in dementia clients
Which concerns are risk factors for the development of Alzheimer's disease (AD)? Select all that apply. Age Sedentary lifestyle High calcium level Past head injuries Family history
Age Past head injuries Family history
Based on Lorena's case, what information will the nurse need to gather? Select all that apply. What Lorena's daily diet consists of Detailed account of what cognitive changes have occurred Lorena's present and family medical history The number of children Lorena has had What medications Lorena is taking
Detailed account of what cognitive changes have occurred What medications Lorena is taking Lorena's present and family medical history
Which nursing diagnoses identified by the nurse are appropriate for Lorena's case? Select all that apply. Altered perception Imbalanced nutrition: more than the body requires Disturbed thought process Acute confusion Risk for injury
Altered perception Risk for injury Disturbed thought process
Which medications should a nurse expect to see in a care plan for an elderly client with Alzheimer's disease (AD)? Select all that apply. Antidepressant Antihypertensive Antipsychotic Cholinesterase inhibitor Diuretic
Antidepressant Cholinesterase inhibitor
The nurse is caring for an elderly client with current sodium level of 121 mEq/L. The client also has a history of congestive heart failure and alcohol abuse. He has not been sleeping during his time in the hospital. During an assessment, the client becomes increasingly agitated towards staff, refusing to believe that he has been in the hospital for weeks. Which intervention is most appropriate for the nurse to implement? Administer haloperidol intramuscularly (IM) per prescription Restrain the client and contact the primary care provider Attempt to reorient the client and use therapeutic communication Check the client's chart to see if any medications could be causing this behavior change
Attempt to reorient the client and use therapeutic communication
A student nurse is assisting in the care of a client with dementia. Which action, if made by the student, requires intervention from the nurse?
Intervention Needed: The student argues with the client about today's date. The student is referring to the client as "sweetheart". The student is trying to hurry the client while they are eating. Intervention NOT needed: The student gives the client directions using gestures or pictures. The student is giving simple instructions to the client.
Click on the "Nurse Notes" tab and view the assessment information. Based on assessment information, which complication of Alzheimer's disease should the nurse identify that Lorena is experiencing? Sundowning Malnutrition Delirium Cognitive decline
Sundowning
When delegating a task, it is important to remember this question: "is this task within my colleague's scope of practice?" The registered nurse (RN) is able to assess a clients nutritional and fluid intake to see if it is appropriate for them and meets their needs. Teaching is also the job of the RN, as well as evaluating safety risks. The licensed practical nurse (LPN) is able to administer prescribed oral medications, reinforce education that was provided by the RN, and check the environment for safety hazards. However, keeping dementia clients safe is everyone's job! The unlicensed assistive personnel (UAP) can help the clients with activities of daily living (ADLs) and eating, as well as documenting intake and output in the medical record.
The registered nurse (RN) is able to assess a clients nutritional and fluid intake to see if it is appropriate for them and meets their needs. Teaching is also the job of the RN, as well as evaluating safety risks. Teach & Evaluate The licensed practical nurse (LPN) is able to administer prescribed oral medications, reinforce education that was provided by the RN, and check the environment for safety hazards. However, keeping dementia clients safe is everyone's job! The unlicensed assistive personnel (UAP) can help the clients with activities of daily living (ADLs) and eating, as well as documenting intake and output in the medical record.
The nurse is evaluating Lorena's judgment and cognitive reasoning abilities. Which of the following questions asked by the nurse would provide valuable insight for Lorena's case?
Valuable: "If you smelled smoke in your house, what would you do?" (Holding up a watch) "What is this object?" "I have drawn a circle. I want you to draw the face of a clock." Not Valuable: "Tell me a story from when you were a child." "What did you have for breakfast today?"
Click on the "Nurese's Notes" tab and view the assessment notes. Which documented assessment information should the nurse act on first? Select the two cues that support your answer.
agitation in the late afternoon Daughter fears her mother may hurt herself when the agitation occurs.