A client with advanced Alzheimer's disease keeps searching the unit for her mother who died many years ago. How should the nurse respond?
Let's go to the activity room and see what's going on
Your mother isn't here - she died long ago
What makes you keep looking for your mother?
You must be upset that you can't find your mother
The Correct Answer is A
Choice A reason: Redirecting to an activity uses distraction to reduce agitation in Alzheimer’s, where hippocampal and cortical degeneration causes disorientation and memory loss. Engaging in familiar activities leverages preserved procedural memory, calming the client without confronting their delusion, which aligns with neurobiological strategies to manage confusion and distress.
Choice B reason: Stating the mother died confronts the client’s delusion, likely increasing agitation due to impaired reality testing from Alzheimer’s-related cortical damage. This approach disregards the client’s cognitive limitations, as memory deficits prevent processing such corrections, potentially worsening emotional distress and behavioral symptoms.
Choice C reason: Asking why the client seeks her mother probes a delusion rooted in Alzheimer’s-related memory loss and hippocampal dysfunction. This may confuse or frustrate the client, as they cannot articulate reasons due to cognitive impairment. Redirection is more effective than exploring motives in advanced dementia.
Choice D reason: Assuming upset and addressing emotional distress may escalate agitation, as Alzheimer’s impairs emotional regulation due to amygdala and prefrontal cortex damage. While empathetic, this response risks focusing on the delusion, which the client cannot process, making redirection to an activity a more effective, neurobiologically informed approach.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A BUN of 18 mg/dL is within normal range (7–20 mg/dL) and does not indicate lithium toxicity. Lithium is renally excreted, and normal renal function, as reflected by BUN, suggests adequate clearance. Toxicity arises from sodium imbalances or dehydration, not directly from normal BUN levels, making this unremarkable.
Choice B reason: A fasting blood glucose of 80 mg/dL is normal (70–100 mg/dL) and unrelated to lithium toxicity. Lithium affects sodium and water balance, not glucose metabolism. Toxicity involves neurological symptoms from elevated serum lithium due to impaired renal clearance, not glycemic changes, so this value requires no further assessment.
Choice C reason: A potassium level of 3.6 mEq/L is within normal range (3.5–5.0 mEq/L) and does not indicate lithium toxicity. Lithium primarily affects sodium reabsorption in renal tubules, not potassium. Toxicity symptoms like tremors or confusion stem from sodium imbalances or high lithium levels, not normal potassium levels.
Choice D reason: A sodium level of 128 mEq/L (normal 135–145 mEq/L) indicates hyponatremia, increasing lithium toxicity risk. Lithium is reabsorbed in renal tubules like sodium; low sodium reduces lithium excretion, elevating serum levels, causing neurological symptoms like tremors or seizures. This requires immediate assessment to prevent toxicity.
Correct Answer is A
Explanation
Choice A reason: Offering dessert to stop yelling uses bargaining, not distraction, and may reinforce agitation in Alzheimer’s, where cortical and amygdala damage impairs emotional regulation. This approach risks escalating distress by focusing on the behavior, which the client cannot control due to neurocognitive deficits, making it ineffective.
Choice B reason: Asking if the client wants to finish the meal focuses on the agitation’s context, potentially worsening distress in Alzheimer’s due to impaired reasoning from cortical degeneration. This confrontational approach does not redirect attention, failing to leverage preserved procedural memory, which distraction techniques use to calm neurobiological agitation.
Choice C reason: Suggesting to watch television is a distraction technique, redirecting attention from agitation triggers in Alzheimer’s. By engaging preserved sensory and procedural memory, it reduces amygdala-driven emotional distress without confronting cognitive deficits, aligning with neurobiological strategies to manage agitation and promote calm in dementia care.
Choice D reason: Stating misunderstanding focuses on the client’s communication deficits, likely increasing frustration in Alzheimer’s due to hippocampal and cortical damage. This does not distract from agitation triggers and may exacerbate distress, as the client cannot process or correct their behavior, making it an ineffective response compared to redirection.
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