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
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?
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.
Question 2 of 5
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?
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.'
Question 3 of 5
Which nursing action is most helpful in managing the positive symptoms of schizophrenia?
Correct Answer: C
Rationale: Positive symptoms of schizophrenia include delusions, hallucinations, and fluent but disorganized speech. Positive symptoms are managed by medication administration. Therapeutic communication, physical activity, and drawing are excellent ways to express emotions.
Question 4 of 5
The nurse is instructing the parents of a 21-year-old with schizophrenia who hears voices. Which response by the parent to the child validates that the parent understands the discharge teaching?
Correct Answer: D
Rationale: The parent is most correct to state not hearing the voices but then asking the client to share what the voices are saying. By identifying the content of the hallucinations, the parent can determine the safety of the client or if others are in jeopardy. Also, the parent is correct to call the auditory hallucinations by the term 'the voices.'
Question 5 of 5
The nurse is caring for a client with Alzheimer disease. When discussing neuron damage, which statement best represents the cause of neuron death?
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.