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Which family-centered nursing diagnosis is a priority for Alzheimer disease clients who have a spouse providing care?
- A. Altered Health Maintenance
- B. Fatigue
- C. Caregiver Fatigue
- D. Grief
Correct Answer: C
Rationale: A priority family-centered nursing diagnosis related to a spouse who is providing care is Caregiver Fatigue. The nurse determines family-specific interventions that can assist the spouse or family in care for themselves while caring for the client. Altered Health Maintenance is a client diagnosis. Fatigue and Grief are also potential diagnoses but not as high a priority as Caregiver Fatigue.
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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 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.
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.
The nurse is providing community education regarding Alzheimer disease. Which client scenario is best for the client with progressing Alzheimer symptoms?
- A. Transfer the client to a behavioral health unit.
- B. Place the client in a personal care home.
- C. Place the client in a long-term care dementia unit.
- D. Maintain the client in the home and bring assistance to the care provider.
Correct Answer: D
Rationale: The best client scenario allows the client to remain in the familiar environment of the client's home while maintaining safety. Home health nurses and nurse aides can aid families in managing client care. Transferring clients to the behavioral health unit, to a personal care home, or a dementia unit all take the client from the home setting, which can be confusing.