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
The client asks the nurse if there is a diagnostic test that confirms the diagnosis of Alzheimer disease. Which response by the nurse identifies how the diagnosis is confirmed?
Correct Answer: A
Rationale: Much research is being done to determine a diagnostic test confirming Alzheimer disease. The nurse is most correct to confirm that Alzheimer disease is currently validated by noting mental decline and ruling out all other disease processes. Upon autopsy, neurofibrillary tangles are noted. There currently is not a test using biomarkers for Alzheimer disease. An MRI is used to exclude other disease processes and is not specific for Alzheimer disease. Acetylcholine may result in cognitive deficits but is not found in the spinal fluid.
Question 2 of 5
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?
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.
Question 3 of 5
A family brings a parent to the physician's office to discuss the parent's decline in cognitive status. The family states that the parent is forgetful and needs reminders to be able to live alone. Following assessment, which stage of Alzheimer disease does the nurse anticipate?
Correct Answer: C
Rationale: The nurse is most correct to anticipate that the client will be diagnosed at the mild cognitive impairment stage of Alzheimer disease. At this stage, the client has noticeable memory problems, however, the memory loss is not serious enough to interfere with independent living.
Question 4 of 5
Which of the following nursing diagnoses would be of highest priority for a client diagnosed with advanced Alzheimer disease?
Correct Answer: D
Rationale: When identifying a priority, select the diagnosis that could be the most harmful. The nurse is most correct to select Aspiration Risk as the highest priority. Aspiration can potentially cause pneumonia. Memory Impairment and Chronic Confusion are manageable with appropriate supervision. Impaired Verbal Communication is an obstacle in expressing thoughts and feelings.
Question 5 of 5
The nurse is providing community education regarding Alzheimer disease. Which client scenario is best for the client with progressing Alzheimer symptoms?
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.