HESI Neurocognitive Disorder (Advanced Alzheimer's Disease)

#21 Which option provides the best respite for the spouse?

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.

#29 The nurse obtains the following assessment data: T 96.8° F (36° C), HR 98 beats/min, R 22 breaths/min, BP 84/44 mmHg, O2 saturation 96%. After the nurse assists the client back to the bed, which nursing action has the highest priority?

Educate unlicensed staff about the need for the patient to rise slowly and ensure close monitoring. 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.

#13 The nurse identifies "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. Which intervention should the nurse include in the client and family teaching?

Help Patient to 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.

#15 Which technique is most useful in helping a client with AD recognize the bathroom?

Place a picture of a toilet on the door. (Picture recognition is a useful tool in helping the client with AD)

#22 One morning a week, the spouse participates in a caregiver support group. He finds that sharing his frustrations and concerns with other people experiencing the same situation provides comfort and support, as well as some useful caregiver tips. One male member of the support group jokes about the problems he has taking care of his spouse. How should the nurse facilitator respond to this participant's joking behavior?

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.

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

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.

#14 The client's spouse reports that the client frequently makes statements that are inaccurate, but he is reluctant to correct her too often, because she told him that it makes her feel stupid.

Reinforce that it is right to balance the client's 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.

#17 The client's current behaviors include increasing memory loss, frequent wandering, inability to perform self-care when she is feeling highly stressed, urinary incontinence, and limited ability to maintain a conversation. The spouse asks the nurse what to expect next. Which is the best response by the nurse?

"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.

#12 Which information indicates possible serious side effects of trazodone?

-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. -The client is complaining of dizziness upon standing. Orthostatic hypotention can cause dizziness and potential for falls and injury. -The client is also 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.

#16 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. The nurse's response should be based on which understanding about Alzheimer's disease?

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. This most correctly describes the course of Alzheimer's disease.

#10 Since the client is likely to be taking donepezil for a long period of time, the nurse reviews the side effects with the client's spouse. Which side effect should the nurse instruct the spouse to report immediately?

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

#7 Which question is best to ask Mary and her husband to elicit information about possible risk factors of Alzheimer's disease?

Does anyone in your family have 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.

#8 Since the lab test results are normal, and neuroimaging tests are consistent with Alzheimer's disease, the nurse develops 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. How should the nurse explain the therapeutic effect of donepezil to the couple?

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

#11 Two months later Mary's husband calls to update nurse. Which information indicates that the Trazodone is having the desired effect?

Mary sleeps through the night. (Trazodone is an antidepressant often used to improve sleep with AD patients)

#4 The client's laboratory tests include a CBC, TSH, T3, T4, electrolytes, BUN, and glucose levels. The results are all normal. How should the nurse explain the information to the client's spouse?

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.

#24 A client at the care center with late-stage Alzheimer's disease becomes distraught when staff members attempt to reorient him to reality. Immediately after lunch, he starts yelling in a loud voice that he is hungry and wants his lunch. What action should the nurse implement?

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.

#25 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 Medical Center 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. What action should the nurse implement first?

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.

#3 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.

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.

#2 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. Select all that apply

-Level of consciousness is an assessment of the client's cognition -Remote memory is an assessment of the client's cognition

#19 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?

-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. -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. -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.

#23 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?

-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. -Ensure opportunities for physical activity. Promoting physical mobility is an important goal. -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. -Incorporate pet therapy. Pet therapy is another form of sensory stimulation that may calm clients with Alzheimer's disease.

#27 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. Oxazepam 15 mg tablet po prn anxiety every 4 hours is prescribed. 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 tablet15mg (prescribed dose) / 30 mg (on hand or available supply) = 0.5 or 1/2

#9 The client's spouse says that he knows this disease will worsen and wants to know if they should wait to use this medication until the client really needs it. How should the nurse respond?

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.

#33 The spouse begins to cry. What initial intervention should the nurse implement?

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.

#28 Two hours later, the UAP assists the client to a chair. Moments later the UAP reports to the nurse that the client is sitting in a chair and finally seems ready to settle down for the night, however she is weak, drowsy, and diaphoretic. What action should the nurse take?

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.

#31 After being discharged from the Medical Center, the client is visited by the home health RN every other week, a home health PN twice a week, and a home health aide three times a week. The client's condition gradually worsens. Which member of the home care team should be assigned to revise the client's plan of care to reflect her changing condition?

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 from the PN and home health aide.

#20 Which questions are most important to ask the spouse before developing the plan of care?

-Ask how their children are coping with their mother's disease. This will provide useful information to ascertain whether the children are helping the spouse or whether their response is adding to his stress; however, the nurse should involve the children in the conversation to teach the family about the need to provide respite for their father. -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. -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. -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.

#18 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?

-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. -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. -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. -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.

#32 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. Which response is best for the nurse to provide?

-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.

#30 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. Which task can be delegated to the practical nurse (PN)? (Select all that apply. One, some, or all options may be correct.

-Observe the IV site for phlebitis while discontinuing the IV. This involves assessment of a potentially new problem and is best performed by the registered nurse. -Administer the first scheduled dose of the prescribed oral antibiotic. This action is within the scope of practice of the PN. -Calculate the client's intake and output for the shift. This action is within the scope of practice of the PN.

#26 While the nurse is talking with the client and securing the IV site with a cling gauze dressing, the charge nurse enters the room assessing the client's behavior and says that she will prepare oxazepam, a medication to calm the client. The client still appears frustrated and acting out while complaining about her hip hurting. What are appropriate responses by the nurse?

-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. -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. -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. -The client says her hip hurts and she has a prescription 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.

#5 Which understanding by the nurse regarding Alzheimer's disease is accurate?

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.

#1 The nurse administers a mental status exam to assess cognitive function. This exam includes which component?

Judgment. (Eval includes assess of attention, concentration, judgment, perception, learning, memory, communication, language, and speed of processing information.)