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Case Study: Neurocognitive Disorder (Alzheimer's Disease)
Terms in this set (32)
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.)
When the nurse is assessing Mary's cognitive function, which questions are appropriate to include in the mental status exam? SATA
Ask mary to list three different types of fruits, colors and animals.; give mary a photo of a circle and ask her to fill in the times on the clock; Ask mary what she would do if she smelled gas in the house. (no complex tasks)
Which example represents the forgetfulness typical of Alzheimer's disease?
Forgetting to serve dinner after preparing the meal.
Mary's husband states, "Mary just doesn't act like herself anymore." Which response by the nurse is best?
Changes in behavior and personality often occur in early Alzheimer's disease.
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?
Mary is scheduled for MRI and PET. Mary's husband asks the nurse what these tests will show. What is the best response by the nurse?
The HCP is looking for changes in the brain that are consistent with Alzheimer's disease or for other conditions that can cause Mary's symptoms.
Mary's lab test include a CBC, TSH, T3, T4, electrolytes, BUN and glucose. The results are normal. How should the nurse explain this information to Mary and her husband?
Normal lab test results help rule out other causes of the symptoms.
The nurse should explain the therapeutic effect of donepezil (Aricept) to the couple?
Stabilizes cognitive decline. (Aricept) is an acetylcholinesterase inhibitor, is used in AD to delay the onset of cog decline.
Mary's husband wants to wait until Mary worsens before they start the medication. How should the nurse respond?
This medication provides the most benefit to persons with early-stage AD, so it is important to start it right away.
Because Mary is taking Aricept, the nurse should schedule her for lab test in 6 months. Which lab test should be scheduled?
Serum liver enzymes. (Liver toxicity is a side effect of acetylcholinesterase inhibitors.)
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)
Which information indicates possible serious side effect of trazodone. SATA
Mary is also taking MAOI; Mary is c/o perineal pain (rare side-effect is engorgement of clitoris or penis); Mary has a history of cardiac disease. (Trazodone may exacerbate coronary problems).
Which information should the nurse given in client and family teaching?
Help Mary to recognize the strong emotions that she is feeling. (goal of cognitive restructuring in the client is to challenge the client to alter distorted thought patterns and view reality)
Sam reports that Mary frequently makes statements that are inaccurate, but he is reluctant to correct her too often, because she says she feels stupid. What is the best response by the nurse?
You are right to balance her feelings with the need to promote reality. (As AD progresses, reality orientation often causes the client to become agitated.)
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)
Sam calls and advises that Mary is deteriorating more quickly than he was expecting. He states it's only been 2 years. I thought this disease progressed slowly, Am I doing something wrong. What response should the nurse give regarding AD?
AD is a chronic disease that can progress with no set sequence and that has a typical lifespan of 5 to 20 years.
Sam says Mary's behaviors include increasing memory loss, frequent wandering, inability to perform self-care, high stress, urinary incontinence, and limited ability to maintain a conversation. He 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.
The nurse provides teaching to help reduce Mary's urinary incontinence. Which actions should Sam initiate? SATA
Keep a commode at the bedside; Take mary to bathroom every 2 hours; Establish a toileting schedule at the same time daily.
The nurse is concerned that Mary will develop sundowning syndrome. Which instructions should be included when teaching SAM some measures to reduce this problem? SATA
Provide mary with a relaxing backrub at bedtime; keep some light on in the bedroom at night; provide a calm atmosphere during the day
The nurse recognizes Sam is experiencing caregiver role strain. What questions are most important to ask Sam before developing the plan of care for Sam? SATA
How are your children coping with Mary's disease; What do you find most stressful in your daily life?; What activities do you attend outside your home?
The nurse recognizes that caregivers need respite from the constant demands. Which option provides the best respite for Sam?
Adult day care for Mary.
Sam goes to a meeting one morning a week with people who are experiencing the same situation. One male member of the group jokes about the problems he has taking care of his spouse. How should the nurse respond to this person's joking behavior?
Encourage all group members to use humor as a coping mechanism.
To promote the well-being of a group of clients with AD, which goals are important for a nurse-manager of an adult day care center to include in the Plan of Care? SATA
Provide forms of moderate sensory stimulation (avoid overstimulation); Ensure opportunities for physical activity; Maintain a clam, consistent environment; Encourage group involvement (note a client with severe AD may no longer be capable of understanding the concept of group); Incorporate pet therapy.
A client with late stage AD becomes distraught when members try to reorient him to reality. Immediately after lunch, he starts yelling and screams in a loud voice that he is hungry. Which action should the nurse implement?
Provide a snack so the client can eat. (this is validation therapy and is useful intervention to reduce client agitation)
Mary has an infection and is admitted. By the second day of hospitalization, Mary's behavior becomes agitated. While the nurse is administering antibiotics she tries to climb out of bed and demonstrates hostile, belligerent behavior towards the nurse. What action should the nurse implement first?
Redirect Mary's attention to holding a stuffed animal.
charge nurse is going to administer oxazepam (Serax), an anti-anxiety medication. What is the best response by the nurse? SATA
mary needs to be calmed down immediately. Her husband is upset.; The medication will prevent Mary from harming herself; We may not need to administer a medication. Let me try to calm her; Mary says her hip hurts, she has an RX for pain.
The UAP reports that mary is weak, drowsy, and diaphoretic. What action should the nurse take?
Evaluate Mary's vitals signs before transferring her to her bed.
After the nurse assists Mary to the bed, which nursing action has the highest priority
Educate about arising slowly after sitting.
Mary is scheduled to go home. Mary indicates by her behavior that the IV site is painful. Which tasks can be delegated to the LPN. SATA
Administer the first does of PO antibiotic; and Calculate Mary's intake and output for the shift.
mary progressively gets worse at home. Which member of the home care team should be assigned to revise Marys plan of care to reflect her changing condition?
The home health nurse who visits every other week.
Mary is placed in long-term care facility. Sam states, " I think she would be better off if she died, but I feel so guilty for even thinking that." Which response is best for the nurse to provide?
You have many conflicting emotions right now. (This provides Sam with the opportunity to continue to share his concerns.)
Sam starts to cry. Which initial intervention should the nurse implement?
Remain seated next to Sam while he is crying.
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