Nokea
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.
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The nurse is providing discharge instructions to the client being prescribed antipsychotic medications. Which discharge instruction(s) should be included? Select all that apply.
- A. Stop the medication for any side effects.
- B. Double the next dose if you forget one dose.
- C. Report any rhythmic, involuntary movements of the tongue, face, mouth, jaw, or extremities immediately.
- D. Take all antipsychotic medications as directed.
- E. Notify the health care provider if you have hypertension or severe muscle stiffness.
Correct Answer: C,D,E
Rationale: When providing discharge instructions to a client prescribed antipsychotic medications, the nurse should instruct the client to take all medications as directed and notify the health care provider for any side effects including a high fever, increased confusion, dyspnea, tachycardia, hypertension, severe muscle weakness, or loss of bladder control, because these are signs of neuroleptic malignant syndrome. Similarly, the client should immediately report any rhythmic, involuntary movements of the tongue, face, mouth, jaw, or extremities, because these are signs of tardive dyskinesia. The client should not abruptly stop medications or double the dosage at any time.
The nurse is observing the interaction between a parent and child with schizophrenia. The child states, 'The man visiting me said you went on vacation without me.' The parent replies 'There is no man, you are just making that up.' When interacting with the parent privately, which reply from the parent would the nurse suggest?
- A. I am not on vacation. I am here with you.
- B. How can I go on vacation. I do not have any money.
- C. Stop saying that. You know better. No one told you that.
- D. Just forget about that and let's talk about something else.
Correct Answer: A
Rationale: The nurse is correct to suggest not arguing with the client. This can escalate the situation. The nurse should suggest not validating the delusional belief and focus the discussion to the 'here and now.'
The nurse is caring for a client in the mild cognitive impairment stage of Alzheimer disease. When reviewing the client's medication regimen, which medication does the nurse identify as having a neuroprotective property?
- A. Namenda
- B. Vitamin B2
- C. Celebrex
- D. Neurontin
Correct Answer: A
Rationale: The neuroprotective drugs are the newest medications on the market. The newest drug, Namenda, contains memantine, which is a neuroprotective. The other medications are not Alzheimer medications that diminish dementia.
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.
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.