Nokea
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.
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The nurse is discharging four clients from the behavioral health unit. Which client would be the best candidate for long-term inpatient care?
- A. The client experiencing hallucinations
- B. The client with feelings of persecution
- C. The client with a love interest
- D. The client with suspicion and anger
Correct Answer: D
Rationale: Once a client is in the mental health system, every effort is made to avoid institutionalization. The exception is when the client is dangerous to self and others. The nurse is most correct to anticipate the client with suspicion and anger to be the best candidate for long-term inpatient care. Clients who have hallucinations or feelings of persecution and those with a love interest being discharged from a behavioral health unit can be monitored in an outpatient setting.
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 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 24-year-old client newly diagnosed with schizophrenia. The client asks: 'How could this be happening? What is wrong with my brain?' The nurse is most correct to identify which neurotransmitter as having the highest imbalance?
- A. Acetylcholine
- B. Dopamine
- C. Serotonin
- D. Gamma-aminobutyric acid
Correct Answer: B
Rationale: Schizophrenia is characterized as a psychobiologic disease because of findings in brain and neurotransmitter chemistry. Dopamine excess is believed to be the major cause of symptoms, with imbalance of norepinephrine, serotonin, and gamma-aminobutyric acid also playing a role.