Nokea
The client asks the nurse if there is a diagnostic test that confirms the diagnosis of Alzheimer disease. Which response by the nurse identifies how the diagnosis is confirmed?
- A. Alzheimer disease is confirmed by validating mental decline and ruling out other diseases.
- B. Alzheimer disease is confirmed by the presence of biomarkers found in the blood.
- C. Alzheimer disease is evident on an MRI that highlights tangles in the brain.
- D. Alzheimer disease is diagnosed when acetylcholine is found in spinal fluid.
Correct Answer: A
Rationale: Much research is being done to determine a diagnostic test confirming Alzheimer disease. The nurse is most correct to confirm that Alzheimer disease is currently validated by noting mental decline and ruling out all other disease processes. Upon autopsy, neurofibrillary tangles are noted. There currently is not a test using biomarkers for Alzheimer disease. An MRI is used to exclude other disease processes and is not specific for Alzheimer disease. Acetylcholine may result in cognitive deficits but is not found in the spinal fluid.
You may also like to solve these questions
A family brings a parent to the physician's office to discuss the parent's decline in cognitive status. The family states that the parent is forgetful and needs reminders to be able to live alone. Following assessment, which stage of Alzheimer disease does the nurse anticipate?
- A. Preclinical
- B. Post clinical
- C. Mild cognitive impairment
- D. Alzheimer dementia
Correct Answer: C
Rationale: The nurse is most correct to anticipate that the client will be diagnosed at the mild cognitive impairment stage of Alzheimer disease. At this stage, the client has noticeable memory problems, however, the memory loss is not serious enough to interfere with independent living.
The nurse is caring for a client who states: 'Can you tell this man sitting on the chair to leave my room. I am tired of him watching me.' The nurse notes that there is no one else in the room. The nurse would document the client's experience as which of the following?
- A. Delusion
- B. Dementia
- C. Hallucination
- D. Delirium
Correct Answer: C
Rationale: The nurse is correct to document the client's experience of a man in the room as a hallucination. Hallucinations are sensory experiences only the client perceives. They are auditory or visual in nature. A delusion is characterized by a disturbed thinking process. Dementia is the disturbance or decline in memory. Delirium is a sudden state of confusion.
The nurse is caring for a client who is concerned about having the beginning symptoms of Alzheimer disease. Which question is helpful in determining risk factors?
- A. Has your house been tested for high radon levels?
- B. Do you have any family with Alzheimer disease?
- C. How many times a week do you eat red meat?
- D. At which time of day do you experience most symptoms?
Correct Answer: B
Rationale: The nurse asks the client about the family health history. The nurse is correct to understand that if the client has a first-degree relative with Alzheimer's disease, the client's risk for the disease doubles. The other options are not helpful in determining risk factors.
During a multidisciplinary meeting, the group discussed potential signs of tardive dyskinesia noted sporadically in a client. Following the meeting, symptoms progressed for the client. Which medical order does the nurse anticipate?
- A. Reduce the medication dose.
- B. Discontinue the medication.
- C. Provide an adjunct medication.
- D. Begin alternate treatments.
Correct Answer: B
Rationale: Nurses and the multidisciplinary team consistently assess the client taking antipsychotic medications to check for tardive dyskinesia. When symptoms progress, the nurse should report the symptoms immediately because the drug must be discontinued. Reducing the dose, adjunct medications, and alternative treatments would not be the medical orders issued.
The nurse is teaching the family of clients with Alzheimer disease about the disease process. The nurse is using a picture of the brain and highlighting which structures?
- A. Neurotransmitters and cell receptors
- B. Neurofibrillary tangles and amyloid plaques
- C. Brain tissue and receptor sites
- D. Blood vessels with valves
Correct Answer: B
Rationale: The nurse is most correct to instruct the families on neurofibrillary tangles and amyloid plaques. These are characteristic in clients with Alzheimer disease. The other options may have some effect related to the disease but are not characteristic.