HESI Qs Exam #2

What initial action should the nurse take?

Evaluate Mr. Wilson's vital signs before transferring him to his bed.

Which are common components of an advance directive for healthcare? (Select all that apply.)

-Appointment of another person to make healthcare decisions if the client is unable. -Specific or general instruction about physical health care treatment. -Specific or general instruction about mental or psychological healthcare treatment.

What does the nurse suspect that Mr. Wilson is experiencing?

Delirium.

Which lab test should be scheduled?

Serum liver enzymes.

Which question gives the nurse the most information about Mr. Wilson's judgment?

"If you smelled smoke in a movie theater, what would you do?"

What is the best initial response by the nurse?

"Changes in behavior and personality often occur as Alzheimer's disease progresses."

Mr. Wilson's daughter asks about the recent deterioration in her father's functioning. "It's only been one year since his diagnosis. I thought Alzheimer's disease progressed more slowly."

"Everyone responds differently to this disease, but it is likely that his health and daily functioning will continue to decline."

Which response by the RN is most therapeutic?

"I will pull up a chair so that you may sit on the left side of the bed and hold his hand."

Which question is most important to ask Mr. Wilson's daughter before developing the plan of care to address caregiver role strain?

"What do you find most stressful in your daily life?"

Mr. Wilson's daughter cares for her father in their home with the help of the home healthcare team until his Alzheimer's disease progresses to the point where Mr. Wilson is completely bedridden and is no longer able to perform any self-care measures. Mr. Wilson's daughter notifies he nurse that she plans to place her father in a long-term care facility. While speaking with the nurse, the daughter states, "I think he would be better off dead;l I feel so guilty for even thinking that." What is the best response by the nurse?

"You have many conflicting emotions right now."

Mr. Wilson is upset about visiting the Nurse Practitioner (APRN) and he tells the office RN that there is nothing wrong with him. The RN notes that Mr. Wilson's face is flushed and he is wringing his hands. He states that he does not know why he is at the clinic. He stands by the door, shuffling his feet.

"You look worried. How can I make you feel comfortable?"

What is the best response to Mr. Wilson by the nurse?

"| appreciate your cooperation. Tell me what you think is the problem."

Which of the following are risk factors for Alzheimer's Disease? (Select All that apply.)

Advancing Age. Father and uncle had Alzheimer's disease. Previous Head Trauma.

After assisting Mr. Wilson to the bed, which nursing action has the highest priority?

Elevate Mr. Wilson's feet fifteen degrees.

How does Donepezil (Aricept) reduce the symptoms for clients with mild to moderate Alzheimer's disease?

Enhancing Acetylcholine function.

Which of the following memory issues/deficits are related to Mild Neurocognitive disorder due to Alzheimer's disease? (Select all that apply.)

Forgets the purpose or use of an item. Cooks a meal and forgets to serve it. Becomes lost on the client's own street.

Which action should the RN take?

Keep the room well lit during the evening hours.

What is the goal of nursing care for a client with a Neurocognitive disorder due to Alzheimer's disease?

Maintaining optimum function.

What Should the nurse advice the client's daughter to do? (Select all that apply.)

Make sure her father's room has sufficient light. Divert her father's attention with food or drink.

Which information would support this?

Mr. Caudill sleeps through the night.

Which finding is most important for the PN to report to the Home Health RN?

Mr. Wilson has a weak and thready pulse.

Which finding is most concerning to the PN?

Mr. Wilson's eyes water each time he swallows a bite of meat or bread.

What action should the nurse implement first?

Redirect Mr. Wilson's attention to a familiar object from his home.

Which behavior(s) are commonly associated with caregiver role strain? (Select all that apply.)

Reports of physical symptoms such as frequent headaches. Feels a sadness that will not go away Frequently forgets to change care recipient's soiled linens. Withdraws from family and friends.

Which side effect of donepezil (Aricept) is most important for Mr. Wilson's daughter to report to the HCP?

Tarry stool.

What is the foal for the care of a client with mild-to-moderate Alzheimer's disease who takes donepezil (Aricept)?

The client will maintain the highest level of cognitive ability.

What is the best response by the nurse?

You are right to balance her feelings with the need to promote reality