N128 Week 4 - Alzheimer's Disease (Advanced Stages)

Question 17 of 33 Which is the best response by the nurse? "She is showing signs of late-stage disease and she will soon stabilize at her current level of functioning." "Esther's healthcare provider will explain the expected disease progression at your next appointment." "Every person responds differently to the disease, but it is likely that her ability to function will continue to decline." "It is important to maintain a positive attitude and to not worry too much about what will happen next."

"Every person responds differently to the disease, but it is likely that her ability to function will continue to decline." "She is showing signs of late-stage disease and she will soon stabilize at her current level of functioning." Esther's behaviors are common in the early and middle stages of Alzheimer's disease, rather than the late stage. "Esther's healthcare provider will explain the expected disease progression at your next appointment." The nurse should respond to Harry's question by providing appropriate client teaching and emotional support. "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. "It is important to maintain a positive attitude and to not worry too much about what will happen next." This is a block to further communication, and it does not address Harry's concerns.

Question 27 of 33 Fill in the blankOxazepam 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 tablet15mg (prescribed dose) / 30 mg (on hand or available supply) = 0.5 or 1/2

Question 21 of 33 Which option provides the best respite for the spouse? Hospice care for the client. Adult day care for the client. Meals on Wheels service for both the spouse and client. A visiting nurse to assess the client's status.

Adult day care for the client. Hospice care for the client. Hospice care is generally limited to those with a life expectancy of 6 months or less. 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. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 581. Meals on Wheels service for both the spouse and client. This will provide an excellent service by bringing a daily meal, but it will not provide the spouse with respite from caring for the client. A visiting nurse to assess the client's status. A visiting nurse can provide assessment and teaching, but this will not provide spouse with respite from caring for the client.

Question 16 of 33 The nurse's response should be based on which understanding about Alzheimer's disease? Alzheimer's disease is a rapidly progressing disease, with deterioration that results in a typical lifespan of 2 to 5 years. 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. Alzheimer's disease is a chronic, progressive disease with a clearly defined course and a typical lifespan of 20 to 30 years. Alzheimer's disease is a chronic disease that stabilizes after an initial rapid deterioration and has no defined lifespan.

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. Alzheimer's disease is a rapidly progressing disease, with deterioration that results in a typical lifespan of 2 to 5 years. This information regarding typical lifespan and Alzheimer's disease is inaccurate. 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. Harding, M. (2020). Lewis's Medical-Surgical Nursing. (11th edition). St. Louis, Missouri. Elsevier. Pg. 1386. Alzheimer's disease is a chronic, progressive disease with a clearly defined course and a typical lifespan of 20 to 30 years. This information regarding the typical lifespan and Alzheimer's disease is inaccurate. Alzheimer's disease is a chronic disease that stabilizes after an initial rapid deterioration and has no defined lifespan. This information regarding the typical lifespan of Alzheimer's disease is inaccurate.

Question 7 of 33 Which nursing intervention is best when interviewing the client and her spouse to elicit information about possible risk factors for Alzheimer's disease? Ask if there is a family history of depression or manic behavior. Ask if the client has a history of any thyroid gland problems. Ask if the client has a history of a stroke or transient ischemic attacks. Ask if there is any family history of Alzheimer's disease.

Ask if there is any family history of Alzheimer's disease. Ask if there is a family history of depression or manic behavior. There is no identified correlation between other mental illnesses and Alzheimer's disease, although persons with the disease often experience depression, and persons with Down syndrome may experience Alzheimer's disease. Ask if the client has a history of any thyroid gland problems. Thyroid gland problems may cause dementia, but they are not associated with the development of Alzheimer's disease. Ask if the client has a history of a stroke or transient ischemic attacks. Cerebrovascular accidents and transient ischemic attacks, or any problem causing a decrease in blood supply to the brain, may worsen Alzheimer's disease, but a history of stroke is not a risk factor for the disease. 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. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 435.

Section 3 Question 5 of 33 Which understanding by the nurse regarding Alzheimer's disease is accurate? Changes in behavior and personality often occur in early Alzheimer's disease. Behavior changes may indicate that she has already progressed to a later stage of the disease. Behavior changes are probably the result of her effort to cope with her altered mental function. Behavior changes usually indicate that the person is feeling depressed about the situation.

Changes in behavior and personality often occur in early Alzheimer's disease. 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. Behavior changes may indicate that she has already progressed to a later stage of the disease. These changes do not occur only at a late stage of Alzheimer's disease. Behavior changes are probably the result of her effort to cope with her altered mental function. Although this may be a contributing factor, it is not the most accurate information about behavioral changes in Alzheimer's disease. Behavior changes usually indicate that the person is feeling depressed about the situation. Although this may be a contributing factor, it is not the most accurate information about behavioral changes in Alzheimer's disease.

Question 10 of 33 Which side effect should the nurse instruct the spouse to report immediately? Incontinence. Insomnia. Muscle cramps. Dizziness.

Dizziness. Incontinence. Incontinence is concerning but not life threatening. Insomnia. Insomnia can be reported at a routine visit or a scheduled appointment to discuss concerns but is not life threatening. Muscle cramps. Muscle cramps need to be addressed but not immediately life threatening. Dizziness. Dizziness may be a predictor of a serious side effect of syncope and should be reported immediately. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 445.

Question 29 of 33 After the nurse assists the client back to the bed, which nursing action has the highest priority? Administer oxygen per nasal cannula. Notify the healthcare provider of the vital signs. Provide several warm blankets. Educate unlicensed staff about the need for client to rise slowly and ensure close monitoring/frequent rounding.

Educate unlicensed staff about the need for client to rise slowly and ensure close monitoring/frequent rounding. Administer oxygen per nasal cannula. The client's O2 saturation is within normal limits; therefore, administration of oxygen is not warranted. Notify the healthcare provider of the vital signs. Immediate action should be taken before contacting the healthcare provider. Provide several warm blankets. This is an important intervention since the client's temperature is low, but it is not the highest priority. 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. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 210, 214.

Question 22 of 33 How should the nurse facilitator respond to this participant's joking behavior? Confront the man about this inappropriate behavior. Help the man recognize the need to approach his responsibilities seriously. Ask the other members of the group to ignore the man's behavior. Encourage all group members to use humor as a coping mechanism.

Encourage all group members to use humor as a coping mechanism. Confront the man about this inappropriate behavior. Use of humor is an effective coping mechanism. The nurse should, however, ensure that the man is not monopolizing the group. Help the man recognize the need to approach his responsibilities seriously. The use of humor is an effective coping mechanism. Ask the other members of the group to ignore the man's behavior. The use of humor is an effective coping mechanism. 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. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 168.

Question 28 of 33 What action should the nurse take? Evaluate the client's vital signs before transferring her to her bed. Monitor the client's blood glucose level after she is back in her bed. Assist with transferring the client to her bed and turn on a night light. Advise the UAP to turn off the room light and to let the client rest in the chair.

Evaluate the client's vital signs before transferring her to her bed. 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. Skidmore-Roth, L. (2021). Mosby's 2021 Nursing Drug Reference. (34th edition). St. Louis, Missouri. Elsevier. Pg. 658. Monitor the client's blood glucose level after she is back in her bed. There is no reason to anticipate a change in the client's blood glucose level. Assist with transferring the client to her bed and turn on a night light. The client is exhibiting signs of a physiological problem. Nursing assessment is warranted. Advise the UAP to turn off the room light and to let the client rest in the chair. The client is exhibiting signs of a physiological problem. Nursing assessment is warranted.

Question 6 of 33 The client's spouse asks the nurse what are 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. Frequently misplacing the keys to the car. Losing or misplacing valuable objects is seen in searly-stage Alzheimer's disease. The client is still able to function independently. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 438. Needs assistance choosing clothes appropriate for season. The middle-stage of Alzheimer's disease is when the client confueses words, gets frustrated and acts in unexpected ways such as dressing inappropriate for the weather. Wandering off and losing perspective of location. Wandering off is a late-stage of Alzheimer's disease. Requiring assistance with dressing. Requiring assistance with dressing is a late-stage of Alzheimer's disease.

Question 20 of 33 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.) Select all that apply Ask how their children are coping with their mother's disease. Have the spouse say what he finds most stressful in his daily life. Inquire about any participation with a caregiver support group. Evaluate how much time the spouse spends taking care of himself. Find out what activities the spouse attends outside of the home.

Have the spouse say what he finds most stressful in his daily life. Inquire about any participation with a caregiver support group. Evaluate how much time the spouse spends taking care of himself. Find out what activities the spouse attends outside of the home. 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. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 202, 440, 442, 594. Harding, M. (2020). Lewis's Medical-Surgical Nursing. (11th edition). St. Louis, Missouri. Elsevier. Pg. 65. 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. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 202, 440, 442, 594. Harding, M. (2020). Lewis's Medical-Surgical Nursing. (11th edition). St. Louis, Missouri. Elsevier. Pg. 65. Inquire about any participation with a caregiver support group. This will provide useful information for what resources are currently being used. 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. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 202, 440, 442, 594. Harding, M. (2020). Lewis's Medical-Surgical Nursing. (11th edition). St. Louis, Missouri. Elsevier. Pg. 65. 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. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 202, 440, 442, 594. Harding, M. (2020). Lewis's Medical-Surgical Nursing. (11th edition). St. Louis, Missouri. Elsevier. Pg. 65.

Question 13 of 33 Which intervention should the nurse include in the client and family teaching? Play classical music every day at the same time. Provide Esther with a journal to record her thoughts. Help Esther to recognize the strong emotions that she is feeling. Remove family items that may cause Esther to dwell in the past.

Help Esther to recognize the strong emotions that she is feeling. Play classical music every day at the same time. Music therapy helps to reduce agitation, but it is unlikely to promote cognitive restructuring. Provide Esther with a journal to record her thoughts. Journaling is not a skill that most clients with Alzheimer's disease will be able to perform. Help Esther 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. Remove family items that may cause Esther to dwell in the past. Memory techniques are a useful tool that can often assist clients to recognize their identities.

Section 4 Question 8 of 33 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. How should the nurse explain the therapeutic effect of donepezil to the couple? Improves thinking and functioning abilities. Restores destroyed cells. Decreases hallucinations and delusions. Reduces periods of depression.

Improves thinking and functioning abilities. Improves thinking and functioning abilities. Donepezil, classified as an acetylcholinesterase inhibitor, is used in Alzheimer's disease to delay the onset of cognitive decline. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 445. Restores destroyed cells. At the present time, there are no medications that reverse the course of Alzheimer's disease. Decreases hallucinations and delusions. Psychotropic medications are sometimes used to treat the hallucinations and delusions that may accompany dementia. However, donepezil is not an antipsychotic medication. Reduces periods of depression. Antidepressant medications may be used to treat the depression that often accompanies Alzheimer's disease. Donepezil is not an antidepressant, and, in fact, it may cause depression.

Question 32 of 33 Which response is best for the nurse to provide? Tell the spouse most people would feel guilty for thinking that too. Ask the spouse why he feels she would be better off. Remind the spouse that he is likely too tired to think clearly. Instruct the spouse that he is having many conflicting emotions right now.

Instruct the spouse that he is having many conflicting emotions right now. Tell the spouse most people would feel guilty for thinking that too. This response is judgmental and blocks further communication. Ask the spouse why he feels she would be better off. The use of "why" is often perceived as challenging, and it should not be used by the nurse when seeking to maintain therapeutic communication. Remind the spouse that he is likely too tired to think clearly. This response trivializes the spouse's feelings and blocks further communication. 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. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8th edition). St. Louis, Missouri. Elsevier. Pg. 78.

Question 1 of 33 This exam includes which component? Appetite. Judgment. Pupillary response. Babinski's reflex.

Judgment. Appetite. Decreased appetite may occur with Alzheimer's disease as the result of altered cognitive function, but assessment of nutritional status is not included in a mental status exam. Judgment. Evaluation of cognitive function includes assessment of attention, concentration, judgment, perception, learning, memory, communication, language, and speed of processing information. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 229, 578. Pupillary response. Pupillary response provides information about cranial nerve function, rather than cognitive function. Babinski's reflex. Testing for a Babinski's reflex does not provide information about cognitive function.

Question 18 of 33 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.) Select all that apply Keep a commode at the bedside. Keep a bell handy for the client to ring when she needs to void. Take the client to the bathroom every 2 hours. Ask the client if she needs to use the bathroom after meals. Establish a toileting schedule at the same time daily.

Keep a commode at the bedside. Take the client to the bathroom every 2 hours. Ask the client if she needs to use the bathroom after meals. Establish a toileting schedule at the same time daily. 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. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8th edition). St. Louis, Missouri. Elsevier. Pg. 343. Keep a bell handy for the client to ring when she needs to void. This is unlikely to be useful, as the client may not associate the objct of the bell with the need to void. 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. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8th edition). St. Louis, Missouri. Elsevier. Pg. 343, 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. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8th edition). St. Louis, Missouri. Elsevier. Pg. 343. 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. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8th edition). St. Louis, Missouri. Elsevier. Pg. 343.

Question 2 of 33 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. Level of eye contact. Remote memory. Speech articulation. Facial expression.

Level of consciousness. Remote memory. Level of consciousness. Level of consciousness is an assessment of the client's congition. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 114. Level of eye contact. Level of eye contact is an assessment of the client's behavior. Remote memory. Remote memory is an assessment of the client's congition. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 114. Speech articulation. Speech articulation is an assessment of the client's speech. Facial expression. Facial expression is an assessment of the client's appearance.

Section 8 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. Click for image

Neurocognitive Disorder (Alzheimer's Disease) Guidelines for Family Care at Home Intervention Rationale Safe Environment 1. Gradually restrict use of the car. 1. As judgment becomes impaired, client may be dangerous to self and others. 2. Remove throw rugs and other objects in person's path. If client is in hospital or living with family: 2. Minimizes tripping and falling. 3. Minimize sensory stimulation. 3. Decreases sensory overload, which can increase anxiety and confusion. 4. If client becomes verbally upset, listen briefly, give support, then change the topic. 4. Goal is to prevent escalation of anger. When attention span is short, client can be distracted to more productive topics and activities. 5. Label all rooms and drawers. Label often-used objects (e.g., hairbrushes and toothbrushes). 5. May keep client from wandering into other client's rooms. Increases environmental clues to familiar objects. 6. Install safety bars in bathroom. 6. Prevents falls. 7. Supervise client when he or she smokes. 7. Danger of burns is always present. 8. If client has history of seizures, keep padded tongue blades at beside. Educate family on how to deal with seizures. 8. Seizure activity is common in advanced Alzheimer's disease. Wandering 1. If client wanders during the night, put mattress on the floor. 1. Prevents falls when client is confused. 2. Have client wear medical alert bracelet that cannot be removed (with name, address, and telephone number). Provide police department with recent pictures. 2. Client can easily be identified by police, neighbors, or hospital personnel. 3. Alert local police and neighbors about wanderer. 3. May reduce time necessary to return client to home or hospital. 4. If client is in hospital, have him or her wear brightly colored vest with name, unit, and phone number printed on back. 4. Makes client easily identifiable. 5. Put complex locks on door. 5. Reduces opportunity to wander. 6. Place locks at top of door. 6. In moderate and late Alzheimer's-type dementia, ability to look up and reach upward is lost. 7. Encourage physical activity during the day. 7. Physical activity may decrease wandering at night. 8. Explore the feasibility of installing sensor devices. 8. Provides warning if client wanders. Useful Activities 1. Provide picture magazines and children's books when client's reading ability diminishes. 1. Allows continuation of usual activities that client can still enjoy; provides focus. 2. Provide simple activities that allow exercise of large muscles. 2. Exercise groups, dance groups, and walking provide socialization as well as increased circulation and maintenance of muscle tone. 3. Encourage group activities that are familiar and simple to perform. 3. Activities such as group singing, dancing, reminiscing, and working with clay and paint all help to increase socialization and minimize feelings of alienation. |Copyright © 2018 Elsevier Inc.All Rights Reserved. No part of this product may be reproduced or transmitted in any form or by any means, electronic or mechanical, including input into or storage in any information system, without permission in writing from the publisher.

Question 4 of 33 How should the nurse explain the lab information to the client's spouse? The results likely indicate that the disease is in the early stages. It is common for test results to change as the disease progresses. Normal laboratory tests are not typical and may need to be repeated. Normal laboratory test results help rule out other causes for the symptoms.

Normal laboratory test results help rule out other causes for the symptoms. The results likely indicate that the disease is in the early stages. The tests are use to rule out other treatable causes of dementia before a diagnosis of Alzheimer's disease is established. It is common for test results to change as the disease progresses. The tests are use to rule out other treatable causes of dementia before a diagnosis of Alzheimer's disease is established. Normal laboratory tests are not typical and may need to be repeated. Repeating the laboratory tests will not reveal different results unless there was an error in processing. 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. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 331.

Question 30 of 33 Which task can the assigned PN carry out? (Select all that apply. One, some, or all options may be correct.) Select all that apply Observe the IV site for phlebitis while discontinuing the IV. Teach the spouse about the oral antibiotic the client will take at home. Communicate with the social worker regarding the client's discharge needs. Administer the first scheduled dose of the prescribed oral antibiotic. Calculate the client's intake and output for the shift.

Observe the IV site for phlebitis while discontinuing the IV. Teach the spouse about the oral antibiotic the client will take at home. Administer the first scheduled dose of the prescribed oral antibiotic. Calculate the client's intake and output for the shift. 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. Crawford, L. (2020). Fundamentals of Nursing. (2nd edition). St. Louis, Missouri. Elsevier. Pg. 2, 3, 14, 84. 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. Communicate with the social worker regarding the client's discharge needs. Collaboration regarding the plan of care is normally performed by the RN team leader. Administer the first scheduled dose of the prescribed oral antibiotic. This action is within the scope of practice of the PN. Crawford, L. (2020). Fundamentals of Nursing. (2nd edition). St. Louis, Missouri. Elsevier. Pg. 2, 3, 14, 84. Calculate the client's intake and output for the shift. This action is within the scope of practice of the PN. Crawford, L. (2020). Fundamentals of Nursing. (2nd edition). St. Louis, Missouri. Elsevier. Pg. 2, 3, 14, 84.

Question 15 of 33 Which technique is most useful in helping a client with Alzheimer's disease recognize the bathroom? Place a picture of a toilet on the bathroom door. Place a sign that says "bathroom" on the bathroom door. Place a colored flag on the bathroom door. Place a colored strip of tape at the bathroom entrance.

Place a picture of a toilet on the bathroom door. 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. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8th edition). St. Louis, Missouri. Elsevier. Pg. 343. Place a sign that says "bathroom" on the bathroom door. Clients with Alzheimer's disease often lose the ability to read as the disease progresses. Place a colored flag on the bathroom door. The client with Alzheimer's disease is unlikely to associate a colored flag with use of the bathroom. Place a colored strip of tape at the bathroom entrance. Yellow-colored floor or stairway strips are an often used safety measure for the elderly who have visual difficulties. However, this is not a useful technique in helping the client with Alzheimer's disease recognize a bathroom.

Question 24 of 33 What action should the nurse implement? Confront the client about his disruptive behavior. Reorient the client to scheduled meal times. Provide a snack that the client can eat. Reassure the client that he has just eaten.

Provide a snack that the client can eat. Confront the client about his disruptive behavior. Confrontation will increase the client's agitation. Reorient the client to scheduled meal times. In the later stages of Alzheimer's disease, orientation therapy increases the client's agitation. 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. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 438. Reassure the client that he has just eaten. In the later stages of Alzheimer's disease, orientation therapy increases the client's agitation.

Question 23 of 33 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. Select all that apply Provide forms of moderate sensory stimulation. Ensure opportunities for physical activity. Maintain a calm, consistent environment. Encourage games that include high energy levels. Incorporate pet therapy. Submit

Provide forms of moderate sensory stimulation. Ensure opportunities for physical activity. Maintain a calm, consistent environment. Incorporate pet therapy. 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. Stanhope, M. (2020). Public Health Nursing. (10th edition). St. Louis, Missouri. Elsevier. Pg. 883. Ensure opportunities for physical activity. Promoting physical mobility is an important goal. Stanhope, M. (2020). Public Health Nursing. (10th edition). St. Louis, Missouri. Elsevier. Pg. 883. 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. Stanhope, M. (2020). Public Health Nursing. (10th edition). St. Louis, Missouri. Elsevier. Pg. 883. Encourage games that include high energy levels. It is essential to avoid over-stimulation to reduce confusion. Incorporate pet therapy. Pet therapy is another form of sensory stimulation that may calm clients with Alzheimer's disease. Stanhope, M. (2020). Public Health Nursing. (10th edition). St. Louis, Missouri. Elsevier. Pg. 883.

Question 19 of 33 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.) Select all that apply Provide the client with a relaxing backrub at bedtime. Keep some light on in the bedroom at night. Eliminate client's fluid intake after the evening meal. Increase toileting to every hour from supper until bedtime. Provide a calm atmosphere during the day.

Provide the client with a relaxing backrub at bedtime. Keep some light on in the bedroom at night. Provide a calm atmosphere during the day. 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. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 431, 439, 440, 442. Harding, M. (2020). Lewis's Medical-Surgical Nursing. (11th edition). St. Louis, Missouri. Elsevier. Pg. 1395. 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. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 431, 439, 440, 442. Harding, M. (2020). Lewis's Medical-Surgical Nursing. (11th edition). St. Louis, Missouri. Elsevier. Pg. 1395. Eliminate client's fluid intake after the evening meal. It is important to maintain adequate fluid intake to avoid dehydration, which can be a contributing factor to the confusion of the client with Alzheimer's disease, but elimination of evening fluids does not affect sundowning behaviors. Increase toileting to every hour from supper until bedtime. A regular toileting schedule should be maintained, but an hourly schedule is excessive and unnecessary, and does not affect sundowning behaviors. 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. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 431, 439, 440, 442. Harding, M. (2020). Lewis's Medical-Surgical Nursing. (11th edition). St. Louis, Missouri. Elsevier. Pg. 1395.

Question 25 of 33 What action should the nurse implement first? Redirect the client's attention to holding a stuffed animal. Quietly leave the room until the client calms down Assign an unlicensed assistive personnel (UAP) to remain with client. Apply a soft vest restraint and bed alarm.

Redirect the client's attention to holding a stuffed animal. 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. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 444. Quietly leave the room until the client calms down Although it may be useful to leave the room if the client is not likely to harm herself, this is not the first action that the nurse should implement. Assign an unlicensed assistive personnel (UAP) to remain with client. This may be useful, but it is not the first action that the nurse should implement. Apply a soft vest restraint and bed alarm. From an ethical-legal perspective, the use of a physical restraint is always the last choice, and it should be considered only if all other interventions fail to ensure client safety.

Question 14 of 33 What is the best response by the nurse? Instruct the spouse to correct the client's inaccurate statements to promote reality orientation. Reinforce that it is right to balance the client's feelings with the need to promote reality. Tell the spouse that the client is attempting to manipulate him and make sure she gets her own way. Share with the spouse that there is no reason to attempt to correct the client because she will not understand.

Reinforce that it is right to balance the client's feelings with the need to promote reality. Instruct the sponse to correct the client's inaccurate statements to promote reality orientation. Reality orientation is an important tool for the client with early-stage Alzheimer's disease, but it is also important to recognize and respect the client's feelings. 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. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 515. Tell the spouse that the client is attempting to manipulate him and make sure she gets her own way. This statement is judgmental and uncaring. Share with the spouse that there is no reason to attempt to correct the cliet because she will not understand. Reality orientation is an important tool for the client with early-stage Alzheimer's disease, and it should be included in the client's care whenever possible.

Question 9 of 33 How should the nurse respond? 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. 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. 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. 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.

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. 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. Acetylcholinesterase inhibitors, such as donepezil, are most useful in early-stage Alzheimer's disease. 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. Acetylcholinesterase inhibitors, such as donepezil, are most useful in early-stage Alzheimer's disease. 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. This is not the best rationale for the use of donepezil in early-stage Alzheimer's disease. 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. Skidmore-Roth, L. (2021). Mosby's 2021 Nursing Drug Reference. (34th edition). St. Louis, Missouri. Elsevier. Pg. 419. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8th edition). St. Louis, Missouri. Elsevier. Pg. 344.

Question 33 of 33 The spouse begins to cry. What initial intervention should the nurse implement? Quietly leave the room until the spouse is in control of his emotions. Remain seated next to the spouse while he is crying. Reassure the spouse that he is taking the best action. Encourage the spouse to share his feelings at his support group.

Remain seated next to the spouse while he is crying. Quietly leave the room until the spouse is in control of his emotions. At least initially, the nurse should remain with the spouse and provide support. 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. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8th edition). St. Louis, Missouri. Elsevier. Pg. 78. Reassure the spouse that he is taking the best action. Initially, the nurse should offer support by listening to the spouse express his feelings. Encourage the spouse to share his feelings at his support group. Initially, the nurse should offer support by listening to the spouse express his feelings.

Question 12 of 33 Which information indicates possible serious side effects of trazodone? (Select all that apply. One, some, or all options may be correct.) Select all that apply The client is also taking MAOIs. The client is complaining of dizziness upon standing. The client has urinary urgency. The client has a history of depression. The client has a history of cardiac disease.

The client is also taking MAOIs. The client is complaining of dizziness upon standing. The client has a history of cardiac disease. 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. Skidmore-Roth, L. (2021). Mosby's 2021 Nursing Drug Reference. (34th edition). St. Louis, Missouri. Elsevier. Pg. 1253, 1260. The client is complaining of dizziness upon standing. Orthostatic hypotention can cause dizziness and potential for falls and injury. Skidmore-Roth, L. (2021). Mosby's 2021 Nursing Drug Reference. (34th edition). St. Louis, Missouri. Elsevier. Pg. 1253, 1260. The colient has urinary urgency. The client's urinary urgency is not associated with taking trazadone. The client has a history of depression. The client has no current symptoms of depression. Trazodone is an antidepressant frequently used as a medication to induce sleep. 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. Skidmore-Roth, L. (2021). Mosby's 2021 Nursing Drug Reference. (34th edition). St. Louis, Missouri. Elsevier. Pg. 1253, 1260.

Question 26 of 33 What are appropriate responses by the nurse? (Select all that apply.) Select all that apply The client needs to be calmed down immediately. She is upsetting her husband. The medication will prevent the client from harming herself. A medication may not be needed to if distraction is effective. Refuse to allow the charge nurse to give an unneeded medication. The client says her hip hurts and she has an order for pain medication.

The client needs to be calmed down immediately. She is upsetting her husband. The medication will prevent the client from harming herself. A medication may not be needed to if distraction is effective. The client says her hip hurts and she has an order for pain medication. 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. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 442. 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. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 442. 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. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 442. Refuse to allow the charge nurse to give an unneeded medication. This response does not address the client's anxiety or safety; it is also aggressive and demonstrates poor communication. 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. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 442.

Question 11 of 33 Which information indicates the trazodone is having the desired effect? The client sleeps through the night. The client is able to control her bladder at times. The client often wanders around through the house. The client denies feeling any pain.

The client sleeps through the night. The client sleeps through the night. Trazodone is an antidepressant often used to improve sleep in the client with Alzheimer's disease. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8th edition). St. Louis, Missouri. Elsevier. Pg. 434. The client is able to control her bladder at times. Trazodone has no effect on bladder control. The client often wanders around through the house. The client wandering behavior is not an indication of stabilized cognitive functioning. The client denies feeling any pain. Trazodone is not an analgesic.

Question 31 of 33 Which member of the home care team should be assigned to revise the client's plan of care to reflect her changing condition? The nurse manager of the home health agency. The home health RN who visits every other week. The home health PN who visits twice a week. The home health aide who visits three times a week.

The nurse manager of the home health agency. The agency administrator is not the best member of the team to revise the plan of care. 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. Crawford, L. (2020). Fundamentals of Nursing. (2nd edition). St. Louis, Missouri. Elsevier. Pg. 12, 13. The home health PN who visits twice a week. Revision of the plan of care does not fall within the scope of practice of the PN. The PN may collaborate with the RN on modification, but the RN must do the revisions. The home health aide who visits three times a week. Revision of the plan of care does not fall within the scope of practice of the home health aide.

Question 3 of 33 What is the best explanation by the nurse? The tests are only used to help rule out other causes for the client's symptoms, since there are no tests that can be used to diagnose Alzheimer's disease. 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. 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. The imaging test results will be used to analyze the effectiveness of the treatment protocol used to shrink the diseased brain tissue.

The tests are only used to help rule out other causes for the client's symptoms, since there are no tests that can be used to diagnose Alzheimer's disease. 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 Alzheimer's disease. 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. Halter, M. (2018). Varcarolis' Foundations of Psychiatric Mental Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 44. 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. Diagnostic tests are not typically used to stage Alzheimer's disease. The imaging test results will be used to analyze the effectiveness of the treatment protocol used to shrink the diseased brain tissue. Treatment does not shrink the diseased brain tissue.