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 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 2 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.
Question 3 of 5
The nurse is providing discharge instructions to the client being prescribed antipsychotic medications. Which discharge instruction(s) should be included? Select all that apply.
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.
Question 4 of 5
Which of the following is the primary reason for monitoring food and fluid intake and toilet patterns of a client with mental disabilities?
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.
Question 5 of 5
The nurse is caring for a client diagnosed with delirium. What does the nurse know to be true of delirium?
Correct Answer: B
Rationale: Delirium is a sudden, transient state of confusion. The period of confusion depends on the cause of the delirium. Treating the underlying medical condition usually restores mental function.