A nurse is assessing a client who has Stage 4 Alzheimer's disease. Which of the following findings
should the nurse expect?
a. The client requires
... [Show More] assistance with eating.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to still have the ability to
eat without assistance. Clients who have Alzheimer’s disease maintain this ability until Stage 7.
b. The client independently manages personal finances.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to have difficulty
performing complex tasks, such as managing personal finances.
c. The client has bladder incontinence.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to be able to use the
toilet independently. Clients who have Alzheimer’s disease maintain continence until Stage 6.
d. The client is able to identify the names of family members.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to recognize and
identify family members. Clients who have Alzheimer’s disease maintain this ability until Stage 6.
3. A nurse is caring for a client who reports that the television set in the room is really a two-way radio and
states, "voices are coming from the TV and everything we say in the room is being recorded." Which of
the following responses should the nurse make?
a. "What we say is not being recorded."
The nurse should avoid negating the client’s beliefs about the delusion. This response can
promote a defensive client response and interfere with the development of trust in the nurse-client
relationship.
b. "Let's ignore the voices and talk about something else."
The nurse should ask the client directly about what the voices are saying to determine if there is a
safety risk. The nurse should also avoid validating that the voices are real, which promotes the
client’s beliefs about the delusion.
c. "That must be very frightening."
The nurse should respond to the client’s delusion in a calm and empathetic manner. By
acknowledging to the client that the delusion must be frightening, the nurse promotes the nurseclient
relationship.......... [Show Less]