A nurse witnesses a client with late-stage Alzheimer's disease ...

[Yolanda]

A nurse witnesses a client with late-stage Alzheimer's disease eat breakfast. Afterward the client states, I am hungry and want breakfast. How should the nurse respond?
 
  a. I see you are still hungry. I will get you some toast.
  b. You ate your breakfast 30 minutes ago.
  c. It appears you are confused this morning.
  d. Your family will be here soon. Let's get you dressed.

Question 2

A nurse assesses a client with Alzheimer's disease who is recently admitted to the hospital. Which psychosocial assessment should the nurse complete?
 
  a. Assess religious and spiritual needs while in the hospital.
  b. Identify the client's ability to perform self-care activities.
  c. Evaluate the client's reaction to a change of environment.
  d. Ask the client about relationships with family members.

[taylorsonier]

Answer to Question 1

ANS: A
Use of validation therapy with clients who have Alzheimer's disease involves acknowledgment of the client's feelings and concerns. This technique has proved more effective in later stages of the disease, when using reality orientation only increases agitation. Telling the client that he or she already ate breakfast may agitate the client. The other statements do not validate the client's concerns.

Answer to Question 2

ANS: C
As Alzheimer's disease progresses, the client experiences changes in emotional and behavioral affect. The nurse should be alert to the client's reaction to a change in environment, such as being hospitalized, because the client may exhibit an exaggerated response, such as aggression, to the event. The other assessments should be completed but are not as important as assessing the client's reaction to environmental change.