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A client with AD receiving a cholinesterase inhibitor has a nursing diagnosis of Imbalanced Nutrition: Less Than Body Requirements. Which of the following would be most appropriate?
- A. Provide nutritious meals three times a day.
- B. Give foods that have the same consistency.
- C. Encourage careful chewing.
- D. Encourage visitors during mealtime.
Correct Answer: C
Rationale: The nurse should encourage chewing action when feeding. The nurse need not provide nutritious meals three times a day; instead, frequent small nutritious meals would be more beneficial. Offering foods of different consistency and flavor is important in case the patient can handle one form better than another. The nurse should not encourage visitors during mealtime; mealtime should be simple and calm.
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A review of a client's history reveals that the client takes ginkgo. Which of the following would the nurse assess for in the client as a common adverse reaction?
- A. Hyperglycemia
- B. Headache
- C. Hypotension
- D. Rash
- E. GI discomfort
Correct Answer: B,D,E
Rationale: The most common adverse reactions associated with ginkgo include mild GI discomfort, headache, and rash.
A client is prescribed memantine for the treatment of dementia of Alzheimer's disease. The nurse should assess the client for which of the following as a possible adverse reaction?
- A. Confusion
- B. Dyspepsia
- C. Muscle cramps
- D. Vomiting
Correct Answer: A
Rationale: When administering memantine to a client, a nurse should monitor the client for adverse reactions such as dizziness, headache, or confusion. Dyspepsia is an adverse reaction of rivastigmine; muscle cramps are an adverse reaction of donepezil; vomiting is an adverse reaction of rivastigmine and galantamine.
Which condition would require the nurse to cautiously monitor a client who is receiving donepezil?
- A. Hyperthyroidism
- B. Seizure disorder
- C. Renal disease
- D. Asthma
- E. GI bleeding
Correct Answer: B,C,D,E
Rationale: Cholinesterase inhibitors, like donepezil, are used cautiously in clients with renal or hepatic disease, bladder obstruction, seizure disorder, sick sinus syndrome, GI bleeding, history of ulcer disease, and asthma.
After teaching the caregiver of a client prescribed transdermal rivastigmine, the nurse determines that the teaching was successful when the caregiver states which of the following?
- A. I'll apply a new patch every other day.
- B. The patch should be placed on a hairless area.
- C. I'll make sure to put the patch where he can see it.
- D. I can use the same spot once or twice a week.
Correct Answer: B
Rationale: Rivastigmine patches are changed on a daily basis and rotated to a clean, dry, and hairless area. Because the patient is experiencing dementia, the site for application should be where the patient is not able to pick at or remove the patch. The upper or lower portions of the back are recommended for patch administration. Because the same site should not be used more than once every 2 weeks, the caregiver should be instructed to make a chart of the back and indicate where patches have been applied during the last 14 days.
A group of nursing students are reviewing the stages of AD. They demonstrate understanding of the information when they identify which of the following as characteristic of preclinical AD?
- A. Client's changes in thinking are readily evident to family members.
- B. The client may exhibit moderate levels of anxiety.
- C. The ability to function is significantly limited.
- D. There are no cognitive changes noted.
Correct Answer: D
Rationale: Preclinical AD is characterized by no changes in cognitive or functional ability. With mild cognitive impairment, the changes in thinking are noticeable to the client and family members, and the person may experience mild to moderate anxiety. In dementia due to AD, memory, thinking, and behavior limit the person's ability to function.