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The nurse is caring for a client with Alzheimer disease. When discussing neuron damage, which statement best represents the cause of neuron death?
- A. Neurons die from a lack of oxygen.
- B. Neurons die from microtubule disintegration.
- C. Neurons die from an elevated neurotransmitter level.
- D. Neurons die from diminished blood flow.
Correct Answer: B
Rationale: Alzheimer disease includes mutated genes that disrupt the processing of the amyloid precursor protein following a series of steps in which neuron degeneration occurs. The nurse is correct to identify that neurons die from microtubule disintegration. Oxygen level, blood flow, and an elevated neurotransmitter level are not responsible for neuron death.
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A client is taking a traditional antipsychotic medication and is exhibiting grimacing and lip smacking. The nurse would document this side effect as which of the following?
- A. Akinesia
- B. Akathisia
- C. Tardive dyskinesia
- D. Dystonia
Correct Answer: C
Rationale: Tardive dyskinesia occurs when the client makes involuntary muscle movements, usually in the face, such as tongue thrusting, lip smacking, or blinking. Akinesia is pseudo parkinsonism. Akathisia is the inability to sit still. Dystonia is a sudden severe muscle spasm, usually in the neck, tongue, or eyes.
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 who has experienced readmission to the behavioral health unit for an exacerbation of schizophrenia. Which assessment question asked by the nurse identifies a possible cause for the return?
- A. Do you take a generic form of your medications?
- B. When was your last dose of medication?
- C. Are you having any side effects of the medication?
- D. Can you afford to purchase your medication?
Correct Answer: B
Rationale: The nurse is correct to identify that noncompliance with drug therapy is the leading cause of the return of disease symptoms and the need for short-term hospitalization. Asking when the client's last dose of medication was opens communication for when the medication was last administered. If it was not at the prescribed time, the conversation allows the nurse to probe why. Taking a generic medication does not change the effectiveness. Asking if the client can afford the medication or if the medication causes side effects does not directly address the question of noncompliance.
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 obtaining a history from a 68-year-old client reporting memory loss. The nurse is obtaining general data about the client's condition and then asks specifically if the client and family can remember the first symptoms of memory loss. Which report by family members is typical of Alzheimer progression?
- A. Family members remember the exact time when the disease began.
- B. Family members remember that the client forgot a grandchild's birthday.
- C. Family members cannot remember exactly when, small things have occurred over time.
- D. Family members cannot remember when, but it seems that it occurred after a heart attack.
Correct Answer: C
Rationale: The nurse is correct to identify the statement by family members that they cannot remember exactly when the client's symptoms of memory loss began. Alzheimer disease onset is insidious, and symptoms develop slowly over years. Alzheimer disease is not related to or occurs in conjunction with a disease process.