ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 72 Questions
Question 1 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 2 of 5
The nurse is relating medication classifications for Alzheimer type dementia to the pathophysiology of the disease process. Which neurotransmitter do most the medications on the market currently impact?
Correct Answer: B
Rationale: Current drugs approved for treatment of dementia of the Alzheimer type include cholinesterase inhibitors, which increase acetylcholine by inhibiting cholinesterase, the enzyme that degrades it. When these drugs, tacrine (Cognex), donepezil (Aricept), or rivastigmine (Exelon), are administered in the early to middle stages of Alzheimer disease, some clients improve. Only memantine (Namenda) has a different mechanism of action.
Question 3 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 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.