HESI Case Studies–Psychiatric/Mental Health-Neurocognitive Disorder/Alzheimer’s Disease (Mary Stanfield)

1. The nurse administers a mental status examination to assess Mary’s cognitive function. This exam includes which component?
Judgment

2. When the nurse is assessing Mary’s cognitive function, which questions are appropriate to include in the mental status exam? (Select all)
-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

3. Which example represents the forgetfulness typical of Alzheimer’s disease?
Forgetting to serve dinner after preparing the meal

4. 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

5. Which question is best to ask Mary and her husband to elicit information about possible risk factors for Alzheimer’s disease?
“Does anyone in your family have Alzheimer’s disease?”

6. Mary’s husband asks the nurse what these tests will show. What is the best response by the nurse?
“The healthcare provider is looking for changes in the brain that are consistent with Alzheimer’s disease or for other conditions that can cause Mary’s symptoms.”

7. How should the nurse explain this information to Mary and her husband?
“Normal lab test results help rule out other causes of the symptoms.”

8. How should the nurse explain the therapeutic effect of donepezil (Aricept) to the couple?
Stabilizes cognitive decline

9. Mary’s husband states, “I know this disease will worsen. Shouldn’t we wait to use this medication until Mary really needs it?” 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.”

10. Because Mary will be taking donepezil (Aricept), the nurse schedules her for lab tests in 6 months. Which lab test should be scheduled/
Serum liver enzymes

11. Which information indicates the trazodone (Desyrel) is having the desired effect?
Mary sleeps through the night

12. Which information indicates possible serious side effects of trazodone (Desyrel)? (Select all)
-Mary is also taking MAOIs
-Mary is complaining of perineal pain
-Mary has a history of cardiac disease

13. Which intervention should the nurse include in the client and family teaching?
Help Mary to recognize the strong emotions that she is feeling

14. Sam reports that Mary 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.”What is the best response?
“You are right to balance her feelings with the need to promote reality.”

15. 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

16. The nurse’s response should be based on which understanding about Alzheimer’s disease?
Alzheimer’s disease is a chronic disease that can progress with no set sequence and that has a typical lifespan of 5 to 20 years

17. 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.”

18. The nurse provides teaching to help reduce Mary’s urinary incontinence. Which action(s) are most important for Sam to initiate? (Select all)
-Keep a commode at the bedside
-Take Mary to the bathroom every 2 hours
-Establish a toileting schedule at the same time daily

19. The nurse is concerned that Mary will develop sundowning syndrome. Which instructions should be included when teaching Sam some appropriate measures to reduce this problem? (Select all)
-Provide Mary with a relaxing backrub at bedtime
-Keep some light on in the bedroom at night
-Provide a calm atmosphere during the day

20. Which questions are most important to ask Sam before developing the plan of care? (Select all)
-“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?”

21. Which option provides the best respite for Sam?
Adult day care for Mary

22. How should the nurse respond to this person’s joking behavior?
Encourage all group members to use humor as a coping mechanism

23. To promote the well-being of a group of clients with Alzheimer’s disease, which goals are important for the nurse-manager of an adult care center to include in the plan of care? (Select all)
-Provide forms of moderate sensory stimulation
-Ensure opportunities for physical activity
-Maintain a calm, consistent environment
-Encourage group involvement
-Incorporate pet therapy

24. Immediately after lunch, another client starts yelling and screams in a loud voice that he is hungry and wants his lunch. What action should the nurse implement?
Provide a snack that the client can eat

25. While the nurse is administering a dose of antibiotics, Mary attempts to climb out of bed and demonstrates hostile, belligerent behavior toward the nurse. What action should the nurse implement first?
Redirect Mary’s attention to holding a stuffed animal

26. What is the best response by the nurse? (Select all)
-“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 a prescription for pain medication.”

27. Oxazepam (Serax) 15mg tab PO PRN anxiety q4hr is prescribed. Oxazepam (Serax) 30mg is available. How many tablet(s) of oxazepam (Serax) should the nurse administer to Mary?
0.5

28. The UAP reports that Mary is weak, drowsy, and diaphoretic. What action should the nurse take?
Evaluate Mary’s vital signs before transferring her to her bed

29. After the nurse assists Mary to the bed, which nursing action has the highest priority?
Educate about arising slowly after sitting

30. Which task can be delegated to the licensed practical nurse (LPN)? (Select all)
-Administer the first scheduled dose of the prescribed oral antibiotic
-Calculate Mary’s intake and output for the shift

31. Which member of the home care team should be assigned to revise Mary’s plan of care to reflect her changing condition?
The home health nurse who visits every other week

32. While speaking with the nurse, 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.”

33. Sam begins to cry. What initial intervention should the nurse implement?
Remain seated next to Sam while he is crying

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