Nokea
Which of the following is the primary reason for monitoring food and fluid intake and toilet patterns of a client with mental disabilities?
- A. Regular checkup
- B. To identify problems
- C. To determine common symptoms
- D. Physician's record
Correct Answer: B
Rationale: The nurse monitors food and fluid intake and toilet patterns because data collection facilitates problem identification, not as part of a regular checkup or for determining common symptoms. The physician may refer to these records whenever required.
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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 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.
Which of the following is an outcome of the drug memantine (Namenda) in clients with advanced stages of Alzheimer disease?
- A. Less depression
- B. Increased brain excitability
- C. Lessens symptoms
- D. Decreased brain excitability
Correct Answer: C
Rationale: Clients in advanced stages of Alzheimer disease have fewer symptoms when taking memantine than others who were given a placebo.
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.
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.