Alzheimer's Disease (Advanced Stages) HESI Case Study

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1. Meet the Client During a routine physical exam, a

client states that she has become
increasingly forgetful and worries
that old age is catching up with her.
The nurse notes that the client has
difficulty finishing some of her sen-
tences because she forgets com-
mon words and that she is wear-
ing only a thin sweater on a very
cold day. The client is scheduled for
more in-depth evaluation for possi-
ble neurocognitive disorder due to
Alzheimer's disease.

2. Cognitive Function Assessment The nurse administers a men-

tal status examination to assess
the client's cognitive function. The
client's spouse is present during
the exam.

3. This exam included which compo- b. Judgement

nent?
a. appetite Evaluation of cognitive function in-
b. judgement cludes assessment of attention,
c. pupillary response concentration, judgment, percep-
d. babinski's reflex tion, learning, memory, communi-
cation, language, and speed of pro-
cessing information.

4. When the nurse is conducting the a. LOC

client's cognitive function, which com- Level of consciousness is an as-
ponents of the mental status exam sessment of the client's congition.
best assesses the client's cognition?
(Select all that apply. One, some, or all c. remote memory
options may be correct.) Remote memory is an assessment
a. LOC of the client's congition.
b. level of eye contact
c. remote memory

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d. speech articulation
e. facial expression

5. Diagnostic Studies The client is scheduled for lab work

and neuroimaging tests, includ-
ing a magnetic resonance imag-
ing (MRI) and a positron emission
tomography (PET). The client's
spouse asks the nurse what these
tests will show.

6. What is the best explanation by the b. The healthcare provider is look-

nurse? ing for changes in the brain that
a. The tests are only used to help rule are consistent with Alzheimer's dis-
out other causes for the clients symp- ease or for other conditions that
toms since there are no tests that can can cause the client's symptoms.
be used to diagnose Alzheimer's dis-
ease. Although there are no diagnostic
b. The healthcare provider is looking tests that provide a definitive differ-
for changes in the brain that are con- ential diagnosis of Alzheimer's dis-
sistent with Alzheimer's disease or for ease, several imaging tests provide
other conditions that can cause the data that show changes consistent
client's symptoms. with AD. Other problems that cause
c. The tests will provide information dementia may also be found via
about the staging of the Alzheimer's neuroimaging tests.
disease, so the healthcare provider
will know which medications to pre-
scribe for the best treatment.
d. The imaging test results will be used
to analyze the effectiveness of the
treatment protocol used to shrink the
diseased brain tissue.

7. The client's laboratory tests include

a CBC, TSH, T3, T4, electrolytes, BUN,
and glucose levels. The results are all
normal.

8. How should the nurse explain the lab d. Normal laboratory test results
information to the client's spouse? help rule out other causes for the
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a. The results likely indicate that the symptoms.
disease is in the early stages.
b. It is common for test results to There are many causes of demen-
change as the disease progresses. tia, especially in the older client.
c. Normal laboratory tests are not typ- Laboratory tests help rule out treat-
ical and may need to be repeated. able causes before a diagnosis of
d. Normal laboratory test results help Alzheimer's disease is established.
rule out other causes for the symp-
toms.

9. Which understanding by the nurse re- a. Changes in behavior and

garding Alzheimer's disease is accu- personality often occur in early
rate? Alzheimer's disease.
a. Changes in behavior and person-
ality often occur in early Alzheimer's Subtle changes in behavior and
disease. personality, which would easily be
b. Behavior changes may indicate that recognized by a loved one, occur
she has already progressed to a later even in early Alzheimer's disease.
stage of the disease.
c. Behavior changes are probably the
result of her effort to cope with her
altered mental function.
d. Behavior changes usually indicate
that the person is feeling depressed
about the situation.

10. Warning Signs & Risk Factors Early indicators from the mental
status exam show that the client
has impaired cognitive functioning.
The nurse explains to the client and
her spouse that a number of differ-
ent problems can result in altered
cognition. The nurse discusses ear-
ly warning signs and risk factors for
Alzheimer's disease with the cou-
ple. The client's spouse says that
the client does not like herself any-
more.

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11. The client's spouse asks the nurse a. Frequently misplacing the keys
what are typical behaviors for ear- to the car
ly stage Alzheimer's disease. Which
nursing explanation best promotes ef- Losing or misplacing valuable
fective communication? objects is seen in early-stage
a. Frequently misplacing the keys to Alzheimer's disease. The client is
the car still able to function independently.
b. Needs assistance choosing clothes
appropriate for season
c. Wandering off and losing perspec-
tive of location
d. Requiring assistance with dressing

12. Which nursing intervention is best d. Ask if there is any family history
when interviewing the client and her of Alzheimer's disease.
spouse to elicit information about pos-
sible risk factors for Alzheimer's dis- There seems to be a genetic pre-
ease? disposition to the development of
a. Ask if there is a family history of Alzheimer's disease for many in-
depression or manic behavior. dividuals. Genetic testing may be
b. Ask if the client has a history of any useful for the differential diagnosis
thyroid gland problems. because four genes are currently
c. Ask if the client has a history of a associated with the disease. In ad-
stroke or transient ischemic attacks. dition, information about previous
d. Ask if there is any family history of head trauma, exposure to toxic or
Alzheimer's disease. metal waste, or any viral illnesses
should be elicited when the nurse
obtains Esther's history.

13. Medication Therapy Since the lab test results are nor-
mal, and neuroimaging tests are
consistent with Alzheimer's dis-
ease, the nurse and RN team
leader develop a plan of care for the
client and her spouse that is consis-
tent with the medical diagnosis of
Alzheimer's disease. The client re-
ceives prescriptions for trazodone
and donepezil.

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14. How should the nurse explain the ther- a. Improves thinking and function-
apeutic effect of Donepezil to the cou- ing abilities
ple?
a. Improves thinking and functioning Donepezil, classified as an acetyl-
abilities cholinesterase inhibitor, is used in
b. Restores destroyed cells Alzheimer's disease to delay the
c. Decreases hallucinations and delu- onset of cognitive decline.
sions
d. Reduces periods of depression

15. 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 re-
ally needs it.

16. How should the nurse respond? d. Reinforce that this medication
a. Explain that it is a good idea to provides the most benefit to per-
wait because the client's condition will sons with early-stage Alzheimer's
worsen, and she will develop a toler- disease, so it is important to start it
ance to the medication's effect. right away.
b. Tell the spouse that it may be benefi-
cial to wait and not to start the medica- Acetylcholinesterase inhibitors,
tion until the her healthcare provider is such as donepezil, are most use-
available to ask. ful in stabilizing cognitive decline in
c. Inform the spouse that this med- early-stage Alzheimer's disease.
ication has many side effects, and
it should be taken early in the dis-
ease while the client is still physically
strong.
d. Reinforce that this medication pro-
vides the most benefit to persons with
early-stage Alzheimer's disease, so it
is important to start it right away.

17. 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.
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18. Which side effect should the nurse in- d. dizziness

struct the spouse to report immediate-
ly? Dizziness may be a predictor of a
a. incontinence serious side effect of syncope and
b. insomnia should be reported immediately.
c. muscle cramps
d. dizziness

19. The client's spouse calls the nurse 2

months later and gives an update on
the client's condition.

20. Which information indicates the Tra- a. The client sleeps through the
zodone is have the desired effect? night.
a. The client sleeps through the night.
b. The client is able to control her blad- Trazodone is an antidepressant of-
der at all times. ten used to improve sleep in the
c. The client often wanders around client with Alzheimer's disease.
through the house.
d. The client denies feeling any pain.

21. Which information indicates possible a. The client is taking MAOIs.

serious side effects of trazodone? (Se- MAOIs and trazodone are antide-
lect all that apply. One, some, or all pressants that cannot be used in
options may be correct.) conjunction with each other. There
a. The client is taking MAOIs. must be a 2-week period without
b. The client is complaining of dizzi- MAOIs before trazadone is admin-
ness upon standing. istered.
c. The client has urinary urgency.
d. The client has a history of depres- b. The client is complaining of dizzi-
sion. ness upon standing.
d. The client has a history of cardiac Orthostatic hypotention can cause
disease. dizziness and potential for falls and
injury.

d. The client has a history of cardiac

disease.
Trazadone may exacerbate coro-
nary problems, and the HCP needs
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to know this history prior to pre-
scribing trazadone.

22. Distorted Thought Processes The PN and RN team leader identi-

fy "distorted thought processes" as
a priority problem for the client. Fo-
cusing on this problem, the nurse
provides client teaching to the
client's spouse. The nurse instructs
the spouse about measures to pro-
mote cognitive restructuring.

23. Which intervention should the nurse c. Help Esther recognize the strong
include in the client and family teach- emotions that she is feeling.
ing?
a. Play classical music every day at the The goal of cognitive restructur-
same time. ing in the client with early-stage
b. Provide Esther with a journal to Alzheimer's disease is to challenge
record her thoughts. the client to alter distorted thought
c. Help Esther recognize the strong patterns and view the world more
emotions that she is feeling. realistically. One technique is to
d. Remove family items that may cause help the client recognize emotions
Esther to dwell in the past. such as anger, fear, and anxiety.

24. 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.

25. Which is the best response by the b. Reinforce that it is right to bal-
nurse? ance the clients feelings with the
a. Instruct the spouse to correct the need to promote reality.
clients in accurate statements and pro-
mote reality orientation. Reality orientation is an important
b. Reinforce that it is right to balance tool for the client with early-stage
the clients feelings with the need to Alzheimer's disease; however, as
promote reality. the disease progresses, reality ori-
c. Tell the spouse that the client is at- entation often causes the client to
tempting to manipulate him and make become agitated. It is important to
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sure she gets her own way. recognize the feelings and emo-
d. Share with the spouse that there tions of the client with Alzheimer's
is no reason to attempt to correct disease.
the client because she will not under-
stand.

26. The nurse also advises the spouse

that there will come a time when the
client will be unable to recognize the
bathroom and he will need to help her
to prevent toileting accidents.

27. Which technique is most useful in a. Place a picture of a toilet on the

helping a client with Alzheimer's dis- bathroom door.
ease recognize the bathroom?
a. Place a picture of a toilet on the Picture recognition is a useful
bathroom door. tool in helping the client with
b. Place a sign that says "bathroom" Alzheimer's disease locate the
on the bathroom door. bathroom.
c. Place a colored flag on the bathroom
door.
d. Place a colored strip of tape at the
bathroom entrance.

28. Disease Progression The spouse calls the nurse some

time later and reports that the
client's behavior is deteriorating
more quickly than he was expect-
ing. 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.

29. The nurse's response should be b. Alzheimer's disease is a chronic

based on which understanding about disease that can progress with no
Alzheimer's disease? set sequence and that has a typical
a. Alzheimer's disease is a rapidly pro- lifespan of 1 to 15 years with the
gressing disease, with deterioration average being 4-8 years.
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that results in a typical lifespan of 2 to
5 years. This most correctly describes the
b. Alzheimer's disease is a chronic dis- course of Alzheimer's disease.
ease that can progress with no set se-
quence and that has a typical lifespan
of 1 to 15 years with the average being
4-8 years.
c. Alzheimer's disease is a chronic,
progressive disease with a clearly de-
fined course and a typical lifespan of
20 to 30 years.
d. Alzheimer's disease is a chronic
disease that stabilizes after an initial
rapid deterioration and has no defined
lifespan.

30. The client's current behaviors in-

clude increasing memory loss, fre-
quent wandering, inability to perform
self-care when she is feeling high-
ly stressed, urinary incontinence, and
limited ability to maintain a conversa-
tion. The spouse asks the nurse what
to expect next. The nurse explains that
the cognitive impairment will increase,
memory will decrease, and atotal as-
sistance will be needed for activities
of daily living (ADL's) including bowel
and bladder.

31. What is the best response by the c. "Every person responds differ-
nurse? ently to the disease, but it is likely
a. "She is showing signs of late-stage that her ability to function will con-
disease and she will soon stabilize at tinue to decline."
her current level of functioning."
b. "Esther's healthcare provider will This response provides accurate
explain the expected disease progres- information and an opportunity for
sion at your next appointment." further client teaching and emotion-
c. "Every person responds differently al support.

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 Alzheimer's Disease (Advanced Stages) HESI Case Study
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to the disease, but it is likely that her
ability to function will continue to de-
cline."
d. "It is important to maintain a posi-
tive attitude and to not worry too much
about what will happen next."

32. The nurse provides teaching to the a. Keep a commode at the bedside.
spouse to help reduce the client's uri- This may be useful in establishing a
nary incontinence. Which actions are routine to promote continence, and
most important for the spouse to initi- it will provide easy access for noc-
ate? (Select all that apply.) turia.
a. Keep a commode at the bedside.
b. Keep a bell handy for the client to c. Take the client to the bathroom
ring when she needs to void. every 2 hours.
c. Take the client to the bathroom every Continence may be promoted if the
2 hours. client with Alzheimer's disease is
d. Ask the client if she needs to use the taken to the bathroom on a regular
bathroom after meals. schedule of at least every 2 hours
e. Establish a toileting schedule at the during the day.
same time daily.
d. 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.

e. 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.

33. The nurse is concerned that the client a. Provide the client with a relaxing
will develop sundowning syndrome. backrub at bedtime.
Which instructions should be includ- Touch, as well as other relaxation
ed when teaching the spouse some techniques, is useful in reducing

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 Alzheimer's Disease (Advanced Stages) HESI Case Study
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appropriate measures to reduce this the nocturnal confusion referred to
problem? (Select all that apply. One, as sundowning syndrome.
some, or all options may be correct.)
a. Provide the client with a relaxing b. Keep some light on in the bed-
backrub at bedtime. room at night.
b. Keep some light on in the bedroom Maintaining some light in the room
at night. after dark is useful in reducing the
c. Eliminate client's fluid intake after nocturnal confusion referred to as
the evening meal. sundowning syndrome.
d. Increase toileting to every hour from
supper until bedtime. e. Provide a calm atmosphere dur-
e. Provide a calm atmosphere during ing the day.
the day. A calm atmosphere during the day
is useful in reducing the nocturnal
confusion referred to as sundown-
ing syndrome.

34. Caregiver Role Strain The nurse recognizes that the

spouse is experiencing caregiver
role strain and develops a plan of
care for him with the RN team
leader.

35. Which questions are most important b. Have the spouse say what he
to ask the spouse before developing finds most stressful in his daily life.
the plan of care? (Select all that apply. This question will elicit information
One, some, or all options may be cor- concerning the caregiver's percep-
rect.) tions about the stress in his life,
a. Ask how their children are coping which is the most important infor-
with their mother's disease. mation for the nurse to obtain.
b. Have the spouse say what he finds
most stressful in his daily life. c. Inquire about any participation
c. Inquire about any participation with with a caregiver support group.
a caregiver support group. This will provide useful information
d. Evaluate how much time the spouse for what resources are currently be-
spends taking care of himself. ing used.
e. Find out what activities the spouse
attends outside of the home. d. Evaluate how much time the
spouse spends taking care of him-

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self.
This will provide useful information
on the extent of caregiver support
the spouse will need.

e. Find out what activities the

spouse attends outside of the
home.
This will provide useful informa-
tion that will help in the nurse's
discussion with the spouse. The
nurse will need to discuss the ac-
tivities with the spouse to ascertain
whether these activities are provid-
ing respite for him. For example, is
he visiting with friends for a couple
of hours or is he going to the phar-
macy or grocery shopping? The lat-
ter are task-oriented and do not
provide respite.

36. The nurse recognizes that care-

givers need respite from the con-
stant care demands of loved ones with
Alzheimer's disease.

37. What option provides the best respite b. Adult day care for the client.
for the spouse?
a. Hospice Care for the client While the client is still ambulato-
b. Adult Day Care for the client. ry, she can spend several hours
c. Meals on Wheels Service for both a day at an adult day care facili-
the spouse and client ty, which would provide the spouse
d. A visiting nurse to assess the with respite from the constant de-
client's status mands of caring for the client.

38. One morning a week, the spouse par-

ticipates in a caregiver support group.
He finds that sharing his frustrations
and concerns with other people expe-

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 Alzheimer's Disease (Advanced Stages) HESI Case Study
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riencing the same situation provides
comfort and support, as well as some
useful caregiver tips. One male mem-
ber of the support group jokes about
the problems he has taking care of his
spouse.

39. How should the nurse facilitator re- d. Encourage all group members to
spond to this participant's joking be- use humor as a coping mechanism.
havior?
a. Confront the man about this inap- Humor can serve as an effective
propriate behavior. coping mechanism for the caregiv-
b. Help the man recognize the need to er of a client with Alzheimer's dis-
approach his responsibilities serious- ease.
ly.
c. Ask the other members of the group
to ignore the man's behavior.
d. Encourage all group members to
use humor as a coping mechanism.

40. 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.

41. To promote the well-being of a group a. Provide forms of moderate sen-

of clients with Alzheimer's disease, sory stimulation.
which goals are important for the Music and art therapy, as well as
nurse manager of an adult care center other forms of sensory stimulation,
to include in the plan of care? (Select may be a part of the care for clients
all that apply. One, some, or all options with Alzheimer's disease, but it is
may be correct. essential to avoid over-stimulation
a. Provide forms of moderate sensory to reduce confusion.
stimulation.
b. Ensure opportunities for physical b. Ensure opportunities for physical
activity. activity.
c. Maintain a calm, consistent environ- Promoting physical mobility is an

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 Alzheimer's Disease (Advanced Stages) HESI Case Study
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ment. important goal.
d. Encourage games that include high
energy levels. c. Maintain a calm, consistent envi-
e. Incorporate pet therapy. ronment.
To reduce confusion and maintain
function as long as possible, it is
most important that the nurse con-
trol the environment of clients with
Alzheimer's disease. Control of the
environment will prevent over-stim-
ulation and will ensure a consistent
routine. Both are essential to man-
aging the behavior of clients with
Alzheimer's disease who are easily
agitated.

e. Incorporate pet therapy.

Pet therapy is another form of
sensory stimulation that may calm
clients with Alzheimer's disease.

42. A client at the care center with

late-stage Alzheimer's disease be-
comes distraught when staff members
attempt to reorient him to reality. Im-
mediately after lunch, he starts yelling
in a loud voice that he is hungry and
wants his lunch.

43. What action should the nurse imple- c. Provide a snack that the client
ment? can eat.
a. Confront the client about his disrup-
tive behavior. Responding to the client's reality
b. Re-orient the client to scheduled is referred to as validation therapy
meal times. and is a useful intervention to re-
c. Provide a snack that the client can duce client agitation, especially in
eat. the later stages of Alzheimer's dis-
d. Reassure the client that he has just ease.
eaten.

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44. Ethical-Legal Considerations: Use of The client becomes agitated at

Restraints 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 hospi-
tal for IV antibiotics. By the second
day of hospitalization, the client's
behavior becomes increasingly ag-
itated. While the nurse is admin-
istering a dose of antibiotics, the
client attempts to climb out of bed
and demonstrates hostile, belliger-
ent behavior toward the nurse.

45. What action should the nurse imple- a. Redirect the client's attention to
ment first? holding a stuffed animal.
a. Redirect the client's attention to
holding a stuffed animal. The nurse should first attempt to
b. Quietly leave the room until the calm the client by redirecting her
client calms down attention or distracting her from the
c. Assign an unlicensed assistive per- source of the anxiety.
sonnel (UAP) to remain with client.
d. Apply a soft vest restraint and bed
alarm.

46. While the nurse is talking with the

client and securing the IV site with a
cling gauze dressing, the RN charge
nurse enters the room assessing the
client's behavior and says that they
will prepare oxazepam, a medication to
calm the client. The client still appears
frustrated and acting out while com-
plaining about her hip hurting.

47. What are appropriate responses by the a. The client needs to be calmed
nurse? (Select all that apply.) down immediately. She is upsetting
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a. The client needs to be calmed down her husband.
immediately. She is upsetting her hus- The use of an antianxiety med-
band. ication, such as oxazepam, rep-
b. The medication will prevent the resents an appropriate medication
client from harming herself. when used as prescribed to man-
c. A medication may not be needed if age anxiety that is manifested as
distraction is effective. agitation, especially if the behav-
d. Refuse to allow the charge nurse to ior is unsafe, like pulling out the
give an unneeded medication. IV line. Chemical restraints, usually
e. The client says her hip hurts and she antipsychotics, are drugs given for
has an order for pain medication. the specific purpose of inhibiting a
certain behavior or movement.

b. The medication will prevent the

client from harming herself.
The use of an antianxiety medica-
tion prescribed for anxious and ag-
itated 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.

c. A medication may not be needed

to if distraction is effective.
This is an assertive response that
promotes client advocacy and pre-
vents unnecessary chemical re-
straint.

e. The client says her hip hurts and

she has an order for pain medica-
tion.
Assessing the client's complaint of
pain is appropriate because clients
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with Alzheimer's disease may not
be able to ask for pain medication.
Administering the appropriate pre-
scribed pain medication may alle-
viate the client's pain and dimin-
ish her anxiety and agitation. Ad-
ministering appropriate prescribed
medication based on an assess-
ment of the client's overall condition
or symptoms, for example, sleeping
medication for insomnia, antianx-
iety medication to calm an anx-
ious client, or analgesics for pain
management, is not considered a
chemical restraint.

48. A Complication Occurs The nurse is able to redirect the

client's attention and reduce her
agitation. However, throughout the
day, the client continues to wan-
der 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.

49. Oxazepam 15 mg tablet by mouth (PO) 0.5

as needed (PRN) for anxiety every 4
hours is ordered. Oxazepam 30 mg is D/H x V = X15/30 x 1 = 0.5 or ½
available in the automatic medication tablet
dispenser.
How many tablet(s) of oxazepam 15mg (prescribed dose) / 30 mg
should the nurse administer to the (on hand or available supply) = 0.5
client? (Enter numerical value only. If or 1/2

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rounding is necessary, round to the
nearest tenth.)

50. 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 di-
aphoretic.

51. What action should the nurse take? a. Evaluate the client's vital signs
a. Evaluate the client's vital signs be- before transferring her to her bed.
fore transferring her to her bed.
b. Monitor the client's blood glucose The client may be experiencing an
level after she is back in her bed. adverse effect of the medication,
c. Assist with transferring the client to and she should be assessed before
her bed and turn on a night light. further action is initiated.
d. Advise the UAP to turn off the room
light and to let the client rest in the
chair.

52. The nurse obtains the following as-

sessment data:
T 96.8° F (36° C)
HR 98 beats/min
RR 22 breaths/min
BP 84/44 mmHg
O2 saturation 96%.

53. After the nurse assists the client back d. Educate unlicensed staff about
to the bed, which nursing action has the need for client to rise slow-
the highest priority? ly and ensure close monitoring/fre-
a. Administer oxygen per nasal cannu- quent rounding.
la.
b. Notify the healthcare provider of the The client is experiencing postural
vital signs. hypotension secondary to her ini-
c. Provide several warm blankets. tial dose of the anti-anxiety med-
d. Educate unlicensed staff about the ication. The priority nursing action
need for client to rise slowly and en- is to provide patient safety. Postural
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 Alzheimer's Disease (Advanced Stages) HESI Case Study
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sure close monitoring/frequent round- hypotension is a common side ef-
ing. fect that occurs when a client, who
is taking anti-anxiety medication,
stands up too quickly from a lying
or sitting position.

54. Leadership Aspects 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.

55. Which task can the assigned PN carry a. Observe the IV site for phlebitis
out? (Select all that apply. One, some, while discontinuing the IV.
or all options may be correct.) A PN can do a focused assessment
a. Observe the IV site for phlebitis on an IV site and monitor for com-
while discontinuing the IV. plications.
b. Teach the spouse about the oral an-
tibiotic the client will take at home. b. Teach the spouse about the
c. Communicate with the social work- oral antibiotic the client will take at
er regarding the client's discharge home.
needs. A PN is able to instruct their clients
d. Administer the first scheduled dose on medications per their scope of
of the prescribed oral antibiotic. practice.
e. Calculate the client's intake and out-
put for the shift. d. Administer the first scheduled
dose of the prescribed oral antibi-
otic.
This action is within the scope of
practice of the PN.

e. Calculate the client's intake and

output for the shift.
This action is within the scope of
practice of the PN.

56. After being discharged from the hos-

pital, the client is visited by the home

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 Alzheimer's Disease (Advanced Stages) HESI Case Study
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health RN every other week, a PN twice
a week, and a home health aide three
times a week. The client's condition
gradually worsens.

57. Which member of the home care b. The home health RN who visits
team should be assigned to revise every other week.
the client's plan of care to reflect her
changing condition? Revision of the plan of care is best
a. The nurse manager of the home performed by the RN who visits the
health agency. client. It should be based on the
b. The home health RN who visits nurse's assessment, as well as re-
every other week. ports and collaboration with the PN
c. The home health PN who visits twice and home health aide.
a week.
d. The home health aide who visits
three times a week.

58. Therapeutic Communication: Grief 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 complete-
ly 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 speak-
ing 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.

59. Which response is best for the nurse d. Instruct the spouse that he is
to provide? having many conflicting emotions
a. Tell the spouse most people would right now.
feel guilty for thinking that too.
b. Ask the spouse why he feels she This response restates the
would be better off. spouse's feelings and provides the

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c. Remind the spouse that he is likely opportunity for him to continue to
too tired to think clearly. share his concerns.
d. Instruct the spouse that he is having
many conflicting emotions right now.

60. The spouse begins to cry. What initial b. Remain seated next to the
intervention should the nurse imple- spouse while he is crying.
ment?
a. Quietly leave the room until the The nurse should remain with the
spouse is in control of his emotions. spouse and allow him to cry and
b. Remain seated next to the spouse then offer additional support and
while he is crying. options.
c. Reassure the spouse that he is tak-
ing the best action.
d. Encourage the spouse to share his
feelings at his support group.

61. Case Outcome The spouse visits the client in

the long-term care facility until her
death 2 years later. He continues to
work with the support group to as-
sist other caregivers experiencing
the strain of caring for loved ones
with Alzheimer's disease.

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