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A nurse cares for a client with advanced Alchimers disease. The clients caregiver states, She is always wandering off. What can I do to manage this restless behavior? How should the nurse respond?
- A. This is a sign of fatigue. The client would benefit from a daily nap.
- B. Engage the client in scheduled activities throughout the day.
- C. It sounds like this is difficult for you. I will consult the social worker.
- D. The provider can prescribe a mild sedative for restlessness.
Correct Answer: B
Rationale: Several strategies may be used to cope with restlessness and wandering in Alzheimer's disease. Engaging the client in structured activities throughout the day is effective. Daily naps and sedatives are less effective, and consulting a social worker does not directly address the behavior.
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A nurse is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.)
- A. Sodium levels
- B. Clotting factors
- C. White blood cell count
- D. C-reactive protein
- E. Liver enzymes
Correct Answer: A,B
Rationale: Inflammation from meningitis can stimulate the hypothalamus, leading to excessive antidiuretic hormone production, causing syndrome of inappropriate antidiuretic hormone (SIADH); thus, sodium levels should be monitored. Systemic inflammatory response syndrome (SIRS) can lead to coagulopathy and disseminated intravascular coagulation, requiring monitoring of clotting factors. Other values are not specific to meningitis complications.
A client experiences a seizure with jerking of the arms and legs, followed by an immediate loss of consciousness and jerkings of all extremities. How should the nurse document this activity?
- A. Anotic seizure
- B. Toxic-clonic seizure
- C. Myclonicic seizure
- D. Myclonicic seizure
Correct Answer: B
Rationale: The described seizure, characterized by jerking of arms and legs followed by loss of consciousness and generalized jerking, is a tonic-clonic seizure. 'Anotic' and 'myclonicic' are not recognized seizure types, and the correct term is tonic-clonic.
A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. Which a nurse should the nurse needs in this clients teaching?
- A. Take this drug only when you have prodforma symptoms indicating the onset of a migraine headache.
- B. Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches.
- C. This drug will relieve the pain during the arm phase soon after a headache has started.
- D. This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines.
Correct Answer: B
Rationale: Beta blockers are prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client should monitor these side effects. The other responses do not discuss appropriate uses of the medication.
After teaching a client newly diagnosed with spieplety, the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching?
- A. I will drink more water daily to prevent my mouth from getting dry.
- B. This medication will stop me from getting an aura before a seizure.
- C. I will not drive a motor vehicle while taking this medication.
- D. Even when my seizure stop I will continue to take this drug.
Correct Answer: D
Rationale: Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The medication will not stop an aura before a seizure.
A nurse is teaching the daughter of a client who has Alzheimers disease. The daughter asks, Will the medication my mother is taking improve her dementia? How should the nurse respond?
- A. It will allow your mother to live independently for several more years.
- B. It is used to halt the advancement of Alzheimers disease but will not cure it.
- C. It will not improve her dementia but can help control emotional responses.
- D. It will cure the dementia but not improve memory.
Correct Answer: C
Rationale: Medications for Alzheimer's disease, such as cholinesterase inhibitors, do not improve dementia or halt its progression but can help manage symptoms, including emotional responses. The other options are incorrect as they overstate the medication's effects or are not accurate.