ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 72 : Caring for Clients With Dementia and Thought Disorders Questions
Question 1 of 5
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?
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.
Question 2 of 5
Which medication classification is given to counteract extrapyramidal symptoms (EPS)?
Correct Answer: C
Rationale: Anticholinergic drugs such as Artane and Cogentin are given to prevent or relieve EPS. Antidepressants, antianxiety, and anticonvulsant medications are not given to counteract EPS.
Question 3 of 5
Which of the following is an outcome of the drug memantine (Namenda) in clients with advanced stages of Alzheimer disease?
Correct Answer: C
Rationale: Clients in advanced stages of Alzheimer disease have fewer symptoms when taking memantine than others who were given a placebo.
Question 4 of 5
A client diagnosed with schizophrenia is constantly repeating what others say. The nurse would document these symptoms as which of the following?
Correct Answer: C
Rationale: Echolalia is repeating what others say. Loose associations are a sequence of ideas that are slightly connected. Delusions are false beliefs that cannot be changed by logical reasoning. Neologism is the inventing of new words.
Question 5 of 5
The nurse is calling a report to the emergency department from a long-term care facility. The nurse states that the client abruptly experienced a change in mentation including disorientation and confusion. Vital signs are: temperature, 102.2?°F; pulse rate, 88 beats/minute; respiratory rate, 24 breaths/minute, and blood pressure, 152/70 mm Hg. Lungs are clear. Which potential diagnosis would the emergency department physician place in the initial documentation?
Correct Answer: A
Rationale: There is evidence in the stated report that the client is experiencing delirium. Delirium is a sudden, transient state of confusion. Clients with delirium have difficulty processing information. They may be disoriented, confused, and have impaired judgment. Many times, delirium is associated with a high fever, head trauma, brain tumor, drug intoxication or withdrawal, or inflammatory/metabolic disorders of the central nervous system. Alzheimer disease, with dementia being its most common symptom, is a progressive, deteriorating brain disorder. Disorientation is a symptom, not a diagnosis.