naptersy:Concepts orCareior rauents wuun rrovieus ouneCeuravervous
System: The Brain Ignatavicius: Medical-Surgical Nursing,10th Edition
MULTIPLE CHOICE
l. The nurse is teaching the daughter of a client who has middle-stage Alzheimer disease.The daughter asks, "Will the sertraline my mother is taking improve her dementia?" How would the nurse respond about the purpose of the drug? a.It will allow your mother to live independently for several more years." b.It is used to halt the advancement of Alzheimer disease but will not cure it." c."It will not improve her dementia but can help control emotional responses.' d.It is used to improve short-term memory but will not improve problem solving."
ANS:C Drug therapy is not effective for treating dementia or halting the advancement of Alzheimer disease. However, certain psychoactive drugs may help suppress emotional disturbances and manage depression,psychoses,or anxiety.Drug therapy will not allow the client with middle-stage dementia to safely live independently.
DIF:Applying TOP:Integrated Process: Teaching/Learning KEY:Alzheimer diseaseDrug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
2. A client with early-stage Alzheimer disease is admitted to the hospital with chest pain. Which nursing action is most appropriate to manage this client's dementia? 1. Provide animal-assisted therapy as needed. b. Ensure a structured and consistent environment Assist the client with activities of daily living (ADLs) d. Use validation therapy when communicating with the client.
ANS:B The client who has early Alzheimer disease (AD) does not require assistance with ADLs or validation therapy. While animal-assisted therapy may be helpful, some health care agencies do not allow this intervention. Therefore, the most appropriate action is to provide a structured and consistent environment while the client is hospitalized to prevent worsening of the client's symptoms.
DIF:Applying TOP:Integrated Process: Nursing Process: Planning and Implementation KEY:Alzheimer disease, Nursing Interventions MSC: Client Needs Category: Psychosocial Integrity
3. The nurse observes a client with late-stage Alzheimer disease eat breakfast. Afterward the client states, "I am hungry and want breakfast." What is the nurse's best response? a. "I see you are still hungry. I will get you some toast." b."You ate your breakfast 30 minutes ago." C. "It appears you are confused this morning." d."Your family will be here soon. Let's get you dressed."
ANS: A
Use of validation therapy with clients who have late-stage Alzheimer disease involves acknowledgment of the client's feelings and concerns. This technique has proved more effective in later stages of the disease because reality orientation only increases agitation. The other statements do not validate the client's concerns.
DIF:Applying TOP:Integrated Process: Communication and Documentation KEY: Alzheimer disease, Therapeutic communication MSC: Client Needs Category: Psychosocial Integrity
4. The nurse cares for a client with middle-stage (moderate) Alzheimer disease. The client's caregiver states, She is always wandering off. What can I do to manage this restless behavior?" What is the nurse's best response? a.This is a sign of fatigue. The client would benefit from a daily nap. b.Engage the client in scheduled activities throughout the day. c."It sounds like this is difficult for you. I will consult the soci