A client was recently diagnosed with mild Alzheimer’s disease. Which of the statements shared by the client’s child about their risk for Alzheimer’s disease indicates the need for re-teaching? (Select all that apply.)

 

The correct answer is a.

Choice A Reason:

The statement “Ask the client, ‘What are the voices saying to you?’” is correct. Engaging the client in a conversation about their hallucinations can help the nurse understand the content and nature of the hallucinations, which is crucial for assessing the client’s risk of harm to themselves or others. This approach also validates the client’s experience and can help build trust and rapport. It is important to approach the client with empathy and without judgment, as this can help in managing the symptoms more effectively.

Choice B Reason:

The statement “Give the client a PRN dose of benztropine” is incorrect. Benztropine is an anticholinergic medication used to treat extrapyramidal symptoms caused by antipsychotic medications. It is not used to manage auditory hallucinations directly. Administering benztropine without a clear indication could lead to unnecessary side effects and does not address the immediate issue of the hallucinations.

Choice C Reason:

The statement “Call and report the behavior to the physician” is incorrect. While it is important to keep the physician informed about significant changes in the client’s condition, the immediate intervention should focus on addressing the client’s current experience. Reporting the behavior without first attempting to understand and manage the hallucinations may delay appropriate care and support for the client.

Choice D Reason:

The statement “Tell the client, ‘Well, I see you’re distracted right now. We’ll talk more later.’” is incorrect. This response dismisses the client’s current experience and may make them feel misunderstood or ignored. It is important to address the client’s immediate needs and provide support rather than postponing the conversation. Acknowledging the client’s experience and offering to discuss it can help in managing the symptoms and providing appropriate care.

The correct answer is a, b.

Choice A Reason:

The statement “Organize clinical observations” is correct. One of the primary functions of the Mental Status Exam (MSE) is to systematically organize clinical observations. This includes assessing the client’s appearance, behavior, mood, and cognitive functions. By organizing these observations, healthcare providers can create a comprehensive picture of the client’s current mental state, which is crucial for diagnosis and treatment planning.

Choice B Reason:

The statement “Obtain information about the client’s medical history” is correct. The MSE often involves gathering detailed information about the client’s medical history, including past mental health issues, treatments, and any relevant medical conditions. This information helps in understanding the client’s baseline mental status and identifying any changes or abnormalities. It also aids in creating an effective treatment plan tailored to the client’s specific needs.

Choice C Reason:

The statement “Establish limit setting” is incorrect. While limit setting is an important aspect of managing certain mental health conditions, it is not a primary function of the MSE. Limit setting typically involves establishing boundaries and rules to manage behaviors, which is more relevant in therapeutic settings rather than during the assessment phase. The MSE focuses on evaluating the client’s current mental state rather than setting behavioral limits.

Choice D Reason:

The statement “Determine the client’s IQ” is incorrect. The MSE is not designed to measure a client’s intelligence quotient (IQ)4. Instead, it assesses cognitive functions such as memory, attention, and orientation. IQ tests are specialized assessments that require specific tools and are conducted separately from the MSE. The MSE provides a general overview of cognitive functioning but does not quantify intelligence.