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 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.
Question 2 of 5
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?
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.
Question 3 of 5
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?
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.
Question 4 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 5 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.