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A client in the cardiac clinic tells the nurse that he is concerned about his mother, age 75, who lives alone and seems more forgetful. Which statement would be most indicative that the mother may have Alzheimer's disease?
- A. Mom continues to participate in senior center activities each week.'
- B. Mom insists on cooking and cleaning for herself.'
- C. Mom forgot to pay her utility bills last month.'
- D. Mom refuses to stop driving even though her reaction time is very slow.'
Correct Answer: C
Rationale: The correct answer is C because forgetting to pay bills is a common early symptom of Alzheimer's disease due to cognitive decline affecting memory and executive functions. This behavior indicates difficulty with organizing and managing tasks, a hallmark of Alzheimer's. Choices A and B suggest independence and engagement, which are not necessarily indicative of Alzheimer's. Choice D hints at potential safety concerns but does not directly point to cognitive decline related to Alzheimer's.
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In addition to antidepressants, which of the following is usual treatment for postpartum depression?
- A. Antipsychotics
- B. Psychotherapy
- C. Hormone replacement
- D. Temporary removal of the baby from the home
Correct Answer: B
Rationale: Psychotherapy (B) along with antidepressants are the major treatments for postpartum depression. Patients usually are not psychotic (A), hormone replacement (C) is not indicated, and mother and baby should be kept together with support (D).
A patient has schizophrenia and is troubled by negative symptoms, muscle stiffness, and motor restlessness. His Advanced Practice Nurse (APN) is considering changing the patient's antipsychotic medication, haloperidol (Haldol, a typical or first generation antipsychotic drug). For planning purposes, which medication can the nurse assume that the APN will probably choose?
- A. Chlorpromazine (Thorazine)
- B. Clozapine (Clozaril)
- C. Olanzapine (Zyprexa)
- D. Fluoxetine (Prozac)
Correct Answer: C
Rationale: The correct answer is C: Olanzapine (Zyprexa). Olanzapine is an atypical or second-generation antipsychotic known for effectively treating negative symptoms, muscle stiffness, and motor restlessness in schizophrenia. It has a lower risk of extrapyramidal side effects compared to typical antipsychotics like haloperidol. Chlorpromazine (A) is a typical antipsychotic with similar side effect profiles as haloperidol. Clozapine (B) is an atypical antipsychotic but is typically reserved for treatment-resistant cases due to its potential for serious side effects. Fluoxetine (D) is an antidepressant and not typically used for treating the symptoms described in the question. Therefore, the APN will likely choose Olanzapine to address the patient's symptoms effectively with a lower risk of side effects.
Which nursing diagnosis would be appropriate for a patient with Alzheimer disease?
- A. Disorientation related to hyperthermia
- B. Anxiety (moderate) related to dementia
- C. Disturbed sensory perception (visual) related to alcohol abuse
- D. Disturbed thought processes related to irreversible brain disorder
Correct Answer: D
Rationale: The correct answer is D: Disturbed thought processes related to irreversible brain disorder. This nursing diagnosis is appropriate for a patient with Alzheimer's disease because Alzheimer's is characterized by cognitive decline and disturbances in thought processes due to irreversible brain changes. Disorientation related to hyperthermia (A) is not directly associated with Alzheimer's. Anxiety related to dementia (B) is a symptom of Alzheimer's, not a nursing diagnosis. Disturbed sensory perception related to alcohol abuse (C) is not relevant to a patient with Alzheimer's disease. It is crucial to focus on the specific symptoms and characteristics of Alzheimer's disease when selecting the appropriate nursing diagnosis.
What is a common consequence of repeated purging behaviors in bulimia nervosa?
- A. Cardiovascular instability due to electrolyte imbalances.
- B. Improved body image and self-esteem.
- C. Increased appetite and healthy weight gain.
- D. Decreased risk of gastrointestinal complications.
Correct Answer: A
Rationale: The correct answer is A: Cardiovascular instability due to electrolyte imbalances. Repeated purging in bulimia nervosa leads to electrolyte imbalances, particularly hypokalemia, which can result in cardiovascular instability like arrhythmias and cardiac arrest. Other choices are incorrect. B is false as purging behaviors do not improve body image or self-esteem. C is incorrect as purging does not lead to increased appetite and healthy weight gain, rather it disrupts normal metabolism. D is also incorrect as purging behaviors actually increase the risk of gastrointestinal complications.
A client being treated for anorexia nervosa is 5 feet 10 inches tall and weighs 100 pounds. The client believes she is overweight. On the days the client is scheduled to be weighed, the nurse should be prepared for the client to:
- A. eagerly ask for information about her present weight.
- B. dress in several layers of clothing.
- C. suggest that the scale numbers be hidden from her view.
- D. remind the nurse that she is ready to be weighed.
Correct Answer: B
Rationale: Correct Answer: B - Dress in several layers of clothing.
Rationale: An individual with anorexia nervosa often engages in behaviors to manipulate their weight, such as wearing heavy clothing to increase their weight on the scale. This behavior is a result of distorted body image and fear of gaining weight. By dressing in several layers of clothing, the client may attempt to influence the scale reading to align with their perceived body image.
Summary of other choices:
A: Eagerly asking for information about her present weight is unlikely as individuals with anorexia nervosa typically avoid discussions or confrontations related to their weight.
C: Suggesting that the scale numbers be hidden is not as likely as the client may want to see the numbers to validate their belief of being overweight.
D: Reminding the nurse that she is ready to be weighed may occur, but it does not address the behavior of dressing in layers to manipulate weight.