NURSING 201 LP-123467-EXAMS (2 files merged) possible all questions with answers

1. 1 / 1 point During rounds at LMC, you noticed an ordered lab tests on patient “Sehr gut” who complains of chest pain for 6 hours. Which of the following abnormal values would you expect to see if his chest pain is cardiac related? Your Answer: Correct Low potassium of 3.1 Elevated troponin of 4.5 Low glucose of 65 Low hemoglobin of 7.3 2. 1 / 1 point The student nurse is correct if she states which among the following as an early finding in the EKG of her patient diagnosed with myocardium infarction. Your Answer: Correct Disappearance of Q waves Elevated ST segments Absence of P wave Flattened T waves 3. 1 / 1 point Which of the following clinical manifestations is the most common symptom of myocardial infarction? Your Answer: Correct Chest pain Dyspnea (Difficult breathing) Palpitations Edema (fluid accumulation) 4. 1 / 1 point During graded recitation, the clinical instructor asked the student nurse to select among the following actions to help prevent Valsalva's maneuver. The student nurse is correct if she selects. Your Answer: Correct Assume a side-lying position Clench teeth while moving in bed Drink fluids through a straw Avoid holding breath during activity 5. 1 / 1 point 1. Mr. “Ser gut” who is hospitalized following a myocardial infarction asks the student nurse why he is taking morphine. The student nurse explains that morphine: Your Answer: Correct Decrease anxiety and restlessness Dilates coronary blood vessels Helps prevent fibrillation of the heart Prevents shock and relieves pain and anxiety. 6. 0 / 1 point The nurse is speaking at a community meeting about modifiable risk factors of MI. Based on her teaching, which among the following options place an individual at increased risk for MI? Your Answer: Age (men above 45, women above 55) Smoking history of 3 packs per day for 30 years Premature infants. Vigorous exercise 3 times a week 7. 0 / 1 point ACE inhibitor cannot be administered to patients with MI because of its mechanism in the heart. Your Answer: True False 8. 0 / 1 point The onset of Myocardial Infarction occurs sudden, and the process takes 2 to 6 hours to run its course. Your Answer: True False 9. 0 / 1 point Deficient knowledge related to post-MI self-care is a priority nursing diagnosis for myocardial infraction because if a patient is unaware of the disease process and management it could be detrimental, and the life of the patient would be in jeopardy. Your Answer: True False 10. ? / 1 point Identify an ECG finding a patient with Myocardial infraction will manifest. Your Answer: Awaiting score progressive ST elevation in lead V2 to V5 11. 1 / 1 point You're educating a patient about the causes of a myocardial infarction. Which statement by the patient indicates they misunderstood your teaching and requires you to re- educate them? Your Answer: Correct Coronary artery dissection can happen spontaneously and occurs more in women. The most common cause of a myocardial infarction is a coronary spasm from illicit drug use or hypertension. Patients who have coronary artery disease are at high risk for developing a myocardial infarction. Both A and B are incorrect. 12. 1 / 1 point A patient is admitted with chest pain to the ER. The patient has been in the ER for 5 hours and is being admitted to your unit for overnight observation. From the options below, what is the most IMPORTANT information to know about this patient at this time? Your Answer: Correct Troponin result and when the next troponin level is due to be collected Diet status Last consumption of caffeine CK result and when the next CK level is due to be collected 13. 1 / 1 point A patient is being discharged home after receiving treatment for a myocardial infarction. The patient will be taking Coreg. What statement by the patient demonstrates they understood your education material about this drug? Your Answer: Correct "I will take this medication at night." "I will take this medication as needed." "I will monitor my heart rate and blood pressure while taking this medication." "I will take this medication in the morning with grapefruit juice." 14. 1 / 1 point A patient is being discharged home after receiving treatment for a myocardial infarction. The patient will be taking Coreg. What statement by the patient demonstrates they understood your education material about this drug? Your Answer: Correct "I will take this medication at night." "I will take this medication as needed." "I will monitor my heart rate and blood pressure while taking this medication." "I will take this medication in the morning with grapefruit juice." 15. 0 / 1 point A 56-year-old man suffered a myocardial infarction 7 days ago and is recovering in the intensive care unit. If he were to die suddenly at this time, what are the principle microscopic changes you would expect to see in his heart tissue? Your Answer: Focal coagulative necrosis of myocytes Abundant cellular debris and neutrophil infiltration Exuberant macrophage reaction with phagocytosis Fibrosis and scar tissue Fibroblast proliferation 16. 3 / 3 points What is the are the goal of cardiac rehab? (SATA) Your Answer: Correct Curtail the pathophysiologic and psychosocial effects of heart disease Limit the risk for reinfarction or sudden death Relieve cardiac symptoms Retard or reverse atherosclerosis by instituting programs for exercise training, education, counseling, and risk factor alteration Reintegrate heart disease patients into successful functional status in their families and in society. 17. 3 / 3 points What are the indications for Cardiac Rehab?(SATA) Your Answer: Correct Acute myocardial infarction Unstable Angina Coronary artery bypass grafting Uncontrolled Arrhythmias or A-V Block Angioplasty with or without stenting Valve replacement or repair Recent embolism Moderate to severe Aortic Stenosis 18. 1 / 1 point Phase 2 of cardiac rehab is community based. Your Answer: Correct True False 19. 1 / 1 point Nurse Betty is assigned to the following clients. The client that the nurse would see first after endorsement? Your Answer: Correct A 34 year-old post operative appendectomy client of five hours who is complaining of pain. A 44 year-old myocardial infarction (MI) client who is complaining of nausea. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated. A 63 year-old post operative’s abdominal hysterectomy client of three days whose incisional dressing is saturated with serosanguinous fluid. 20. 1 / 1 point Twenty-four hours after admission for an Acute MI, Jose's temperature is noted at 39.3 C. The nurse monitors him for other adaptations related to the pyrexia, including: Your Answer: Correct Shortness of breath Chest pain Elevated blood pressure Increased pulse rate 21. 0 / 1 point A patient arrives in the emergency department with symptoms of myocardial infarction, progressing to cardiogenic shock. Which of the following symptoms should the nurse expect the patient to exhibit with cardiogenic shock? Your Answer: Hypertension. Bradycardia. Bounding pulse. Confusion. 22. 1 / 1 point Mr. MS, who had a myocardial infarction 2 days earlier, has been complaining to the nurse about issues related to his hospital stay. The best initial nursing response would be to: Your Answer: Correct Allow him to release his feelings and then leave him alone to allow him to regain his composure Refocus the conversation on his fears, frustrations and anger about his condition Explain how his being upset dangerously disturbs his need for rest Attempt to explain the purpose of different hospital routines 23. 1 / 1 point Which of the following is the most common symptom of myocardial infarction? Your Answer: Correct Chest pain Dyspnea Edema Palpitations 24. 1 / 1 point A 55-year-old client is admitted with chest pain that radiates to the neck, jaw and shoulders that occurs at rest, with high body temperature, weak with generalized sweating and with decreased blood pressure. A myocardial infarction is diagnosed. The nurse knows that the most accurate explanation for one of these presenting adaptations is: Your Answer: Correct Catecholamines released at the site of the infarction causes intermittent localized pain. Parasympathetic reflexes from the infarcted myocardium causes diaphoresis. Constriction of central and peripheral blood vessels causes a decrease in blood pressure. Inflammation in the myocardium causes a rise in the systemic body temperature. 25. 1 / 1 point A 42-year-old client admitted with an acute myocardial infarction asks to see his chart. What should the nurse do first? Your Answer: Correct Allow the client to view his chart Contact the supervisor and physician for approval Ask the client if he has concerns about his care Tell the client that he isn't permitted to view his chart. 26. 1 / 1 point Based on the following options which modifiable risk factors place your patient at increased risk for MI? Your Answer: Correct Age of 65 Smoking history of 3 packs per day for 30 years Male Vigorous exercise 3 times a week 15/15 Represents depolarization of the left and right atria. (p wave) (r wave progression) (qt interval) (t wave) me reasons for your doctor to request an electrocardiogram (ECG) include: To look for the cause of the chest pain To identify irregular heartbeats To look for the patients chart To see how an implanted pacemaker is working Represents ventricular repolarization and follows the ST segment. (t wave) (p wave) ( r wave progression) (qt interval) Before beginning ECG interpretation, you should check the following details: Check the date and time that the ECG was performed. Check the calibration of the ECG (usually 25mm/s and 10mm/1mV). Confirm the name and date of birth of the patient matches the details on the ECG. Which of the following EKG changes are abnormal findings that may indicate ischemia or injury to the cardiac muscle found on a 12-lead EKG? SELECT-ALL-THAT-APPLY: QT interval narrowing ST-segment depression Lengthening p-waves T-wave inversion ST-segment elevation Tall t-waves A 12-lead ECG is ordered for a recently admitted patient with cardiomyopathy. This test was ordered to assess the patient for which condition? Dysnea Dysrhythmia Arrhythmias Apnea Graphic representation of the electrical activity of the heart ECG BKG ABC GCE What view of the heart do leads V3 and V4 represent? Anterior Septal Lateral Inferior A nurse notices frequent artifact on the ECG monitor for a client whose leads are connected by cable to a console at the bedside. The nurse examines the client to determine the cause. Which of the following items is unlikely to be responsible for the artifact? Tightly secured cable connections. Frequent movement of the client. Leads applied to the limbs. Leads applied over hairy areas. Leads V3 and V4, which are positioned over the front (anterior) of the left ventricle Anterior lead Av lead Lateral lead Lead what are the significant data about the patient on the strip. 1. Date 2. Time 3. Name 4. Age Time Date Vital signs Age Name What are the risks of an electrocardiogram? Obesity Pregnancy Movement during the test Exercise or smoking before the test Certain medicines Fluid buildup in the abdomen (ascites) Leads V5, V6, I and aVL, which look at the heart from the lower and upper aspect of the left side lead Lateral lead AV lead Anterior lead MAJOR EXAM Sensation of palpitations. Causative factors such as caffeine. Precipitating factors such as infection While caring for a client who has sustained an MI, the nurse notes eight PVCs in one minute on the cardiac monitor. The client is receiving an IV infusion of D5W and oxygen at 2 L/minute. The nurse’s first course of action should be to: Your Answer: Correct Increase the IV infusion rate. Notify the physician promptly. Increase the oxygen concentration. Administer a prescribed analgesic. What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Select all that apply. Your Answer: Correct The RR intervals are relatively consistent. One P wave precedes each QRS complex. Four to eight complexes occur in a 6-second strip. The ST segment is higher than the PR interval. The QRS complex ranges from 0.12 to 0.20 second. Atherosclerosis impedes coronary blood flow by which of the following mechanisms? Levofloxacin (Levaquin) 750 mg IVPB is prescribed for a client with pneumonia. The dose is available in 150 mL of 5% dextrose and is to infuse over 90 minutes. The administration set has a drop factor of 15 drops per mL. At how many drops per minute should the nurse regulate the IVPB to infuse? Record your answer using a whole number. 25 A client is diagnosed with emphysema (COPD). For what long-term problem should the nurse monitor this client? localized tissue necrosis carbon dioxide retention increased respiratory rate saturated hemoglobin molecules A nurse assesses that several clients have low oxygen saturation levels. Which client would benefit the most from receiving oxygen via a nasal cannula? has an upper respiratory infection receives many visitors while sitting in a chair has a nasogastric tube for gastric decompression exhibits dry oral mucous membranes from mouth breathing Which of the following are manifestations of a client with COPD? increased anteroposterior chest diameter underdeveloped neck muscles. collapsed neck veins. Increased chest excursions with respiration. Which of the following diets would be most appropriate for a client with chronic obstructive pulmonary disease (COPD)? low fat, low cholesterol diet bland, soft diet low sodium diet high calorie, high protein diet The nurse cares for a client with chronic obstructive pulmonary disease (COPD). The physician orders oxygen via nasal cannula for this client. Which action should the nurse take? Teach the client to adjust the oxygen rate. Change the oxygen tubing each shift. Increase oxygen to 6 litre per minute as needed. Maintain oxygen at 3 litre per minute or less. The nurse assesses the respiratory status of a client who is experiencing an exacerbation of chronic obstructive pulmonary disease (COPD) secondary to an upper respiratory tract infection. Which of the following findings would be expected? normal breath sounds prolonged inspiration normal chest movement coarse crackles and rhonchi Which of the following indicates that the client with chronic obstructive pulmonary disease (COPD) who has been discharged to home understands the care plan? The client promises to do pursed-lip breathing at home The client states actions to reduce pain. The client will use oxygen via a nasal cannula at 5 L/min. The client agrees to call the physician if dyspnea on exertion increases. The nurse instructs a client diagnosed with chronic obstructive pulmonary disease (COPD) about positions to use during times of dyspnea. The nurse recognizes further teaching is necessary when the client states: I will lie flat on my back. I will sit up and rest my elbows on my knees. I will lean up against a wall I will sit up and lean over a table. When developing a discharge plan to manage the care of a client with chronic obstructive pulmonary disease (COPD), the nurse should advise the client to expect to develop respiratory infections easily maintain current status require supplemental oxygen show permanent improvement The nurse is preparing to administer vancomycin 500 mg 1V to the client with pneumonia. The vancomycin is supplied in a 100-mL piggyback that is to be given over 1 hour. At what rate in milliliters per hour should the nurse set the infusion pump? 50 ml/hour (record your answer as a whole number) The nurse is providing teaching to the client with COPD about the purpose of pursed-lip breathing. Which explanation is most appropriate? It reduces upper airway inflammation. It strengthens the respiratory muscles It improves inhaled drug effectiveness. It reduces anxiety by slowing the heart rate. What nursing action will most help a client obtain maximum benefits after postural drainage? administer prn oxygen encourage coughing deeply place the client in a sitting position encourage the client to rest for a half hour A client's arterial blood gas values are as follows: pH, 7.31; PaO2 , 80 mm Hg; PaCO2 , 65 mm Hg; HCO3 – , 36 mEq/L. The nurse should assess the client for cyanosis flushed skin irritability anxiety The nurse reviews arterial blood gas results for his client with chronic obstructive pulmonary disease (COPD). The pH is 7.3, PaCO2 is 56 mm Hg, and HCO3 is 24 mEq/L. Which acid–base imbalance is this client experiencing? respiratory acidosis metabolic acidosis respiratory alkalosis metabolic alkalosis The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). The results are: pH 7.35; PCO2 62 (8.25 kPa); PO2 70 (9.31 kPa) (34 mmol/L); HCO3 34. The nurse should first: apply a 100% non rebreather mask assess the vital signs. reposition the client. prepare for intubation The nurse enters the client’s room after hearing the pulse oximeter alarming and sees the tracing illustrated on the screen. Which action should be immediately taken by the nurse? Call for the acute respiratory response team. Remove the machine and call maintenance. Give oxygen through a nasal cannula or mask. Assess the level of consciousness and skin color. 1. 1 point What is the most important nursing procedure to perform prior to trachestomy care to minimize the risk of infection? Your Answer: Use curtain Hand washing Use sterile gloves Proper waste disposal 2. 1 point Student nurse Kelvin knows that vigorous coughing and manipulation of the tube can result in Your Answer: Accidental decanulation A safe stable airway Deeper cannulation Bleeding of the stoma 3. 1 point Student nurse Mary Lean is correct if she states that Your Answer: The recommended pressure for wall suction in an adult is 50-95 mmhg and for infant and children is 35-50 mmhg The recommended pressure for wall suction in an adult is 120-140 mmhg and for infant and children is 60-100 mmhg The recommended pressure for wall suction in an adult is 100-120 mmhg and for infant and children is 50-95 mmhg The recommended pressure for wall suction in an adult is 100-120 mmhg and for infant and children is 60-100 mmhg 4. 1 point While changing the tapes on a tracheostomy tube, the client suddently coughs vigorously and the tube was dislodged. Nurse Eliza did the correct initial nursing action if she Your Answer: Call the respiratory therapist to reinsert the tracheostomy Call the physician to reinsert the tube Grasp the retention sutures to spread the opening Cover the tracheostomy site with sterile dressing to prevent infection 5. 1 point Nurse James is caring for a patient with a tracheostomy. He notes that the patient has gurgling sounds coming from the trach site, the patient is breathing rapidly, and is trying to cough. Which action should nurse James perform next? Your Answer: Assess and check first the capillary refill in the tubing Assess first the patient lung sounds Suction the opening and the trach tubing Replace the trach tubing wih an ambu-bag and provide two measured breaths 6. 1 point Nurse Darlyn is supervising a student nurse Babylyn who is performing tracheostomy care for a client. Which of the following actions by the student nurse Babylyn should nurse Darlyn intervene? Your Answer: Suctioning the tracheostomy tube before performing tracheostomy care Removing the inner cannula and cleaning using universal precaution Changing the old tracheotomy ties and securing the tube in place Replacing the inner cannula and cleaning the site of the stoma 7. 1 point Nurse Jechelle is performing tracheal suctioning. Which action is essential to prevent hypoxemia during suctioning? Your Answer: Removal of oral and nasal secretions Encouraging the client to deep breath and cough Auscultate the lungs. Administer 100% oxygen before suctioning 8. 1 point Nurse Florante knows that some of the reasons why a physician requests an electrocardiogram (ECG) is because: (SELLECT ALL THAT APPLY) Your Answer: To look for the cause of the chest pain To identify irregular heartbeats To look for the patients chart To see how an implanted pacemaker is working 9. 1 point Graphic representation of the electrical activity of the heart Your Answer: ECG BKG GCE TLC 10. 1 point Nurse Aliza should interfere the newly hired nurse in performing the ECG if: Your Answer: She placed the v5 at the anterior axillary line She placed the v4 at 5th intercoastal space, midaxillay line She placed the v1 at the right sternal border She placed the v6 at 5th intercoastal space, midaxillary line 11. 1 point For the limb leads, Student nurse Kimberly is correct if she placed the color black lead at Your Answer: right arm right foot right arm left foot 12. 1 point Student nurse Trisha doesn't need further instruction if she is PLACING the chest leads in what manner Your Answer: Red, Yellow, Brown, Green, Black, Violet Red, Yellow, Green, Brown, Black, Violet Red, Yellow, Black, Green, Brown, Violet Red, Yellow, Green, Black, Brown, Violet 13. 1 point Before beginning ECG interpretation, Nurse Elaine should check the following details (SELECT ALL THAT APPLY) Your Answer: Confirm the name and date of birth of the patient matches the details on the ECG Check the date and time that the ECG was performed Check the calibration of the ECG (usually 25mm/s and 10mm/1mV). 14. 1 point Nurse Donna Marie knows that are the significant data about the patient on the strip are: (SELECT ALL THAT APPLY) Your Answer: Date Time Name Contact number Age Vital signs 15. 1 point Student nurse Cloe understands that are the risks of an electrocardiogram are: (SELECT ALL THAT APPLY) Your Answer: Movement during the test Exercise or smoking before the test Certain medications Obesity Pregnancy Fluid build up in the abdomen (ascites) 16. 1 point It is the inability to control urinary elimination. Your Answer: Urinary Continence Urinary Incontinence Urinary Retention Urinary Hesitancy 17. 1 point It is a procedure that involves introduction of a rubber or plastic tube through the urethra into the bladder. Your Answer: Urinary Catheterization Intermittent or Straight Catheterization Urinary Retention Indwelling or Retention Catheterization 18. 1 point The following are purposes of urinary catheterization except: Your Answer: To obtain urine specimen for diagnostic purposes To relieve acute and chronic Urinary Tract Infection To empty bladder before, during and after surgery or before certain diagnostic procedures To measure accurately the hourly urine output of critically ill patients 19. 1 point A client who has an indwelling catheter reports “I need to urinate”. Which of the following interventions should the nurse perform? Your Answer: Re-catheterize the bladder with a large gauge catheter Collect a urine specimen for analysis Reassure the client that it is not possible for her to urinate Check to see whether the catheter is patent 20. 1 point The following are preparation before doing the Surgical Scrub, except one. Your Answer: Adjust your cap and mask properly. Check on your fingernails Rinse hands and arms. Remove your jewelries. 21. 1 point You as a sterile person is assisting another member of the sterile team in gowning. As a nurse, you are correct when you hold the opened gown: Your Answer: At the neckline and shoulders At the chest and waist At both sleeves At the edge of the gown 22. 1 point Indwelling catheters are designed to: Your Answer: Use for straight cath to obtain a urine specimen. Use for a patient who is incontinent. Has no balloon for securing in the bladder. Is a foley catheter that is designed to rest securely in the bladder for a limited amount of time. 23. 1 point How many minutes/ seconds should you wash hands thoroughly with soap and water to about 3 inches above the elbow. Your Answer: 1 ½ minutes 60 seconds 2 minutes 30 seconds 24. 1 point After scrubbing, Nurse Maxwell is about to dry his arm after his hand, he holds the towel in the opposite hand, using what motion should he dry his arm? Your Answer: Circular motion Oscillating motion Short horizontal motion Firm motion 25. 1 point What is the difference between a male and female catheter? Your Answer: Male and female catheters are different colours. Male catheters are longer than female catheters. Male catheters are bigger than female catheters. Female catheters are longer than male catheters. 26. 1 point Who is the head of the surgical team? Your Answer: Anaesthesiologist Surgeon Circulating Nurse Female catheters are longer than male catheters. 27. 1 point You are correct when you put on the gloves when donning PPE if: Your Answer: Gloves fit under cuff of gown. Gloves fit over cuff of gown 28. 1 point True or False: Circulating nurse should assist by opening the pack containing the sterile gown (folded inside out). Your Answer: True False 29. 1 point True or False: The correct sequence for donning PPE is the following: gloves, mask/respirator, goggles/face shield, gown. Your Answer: True False 30. 1 point The anaesthesiologist is responsible for managing the patient's level of consciousness during the procedure. Your Answer: True False 1. 0.8 / 1 point These are all considered as immunologic criteria of systemic lupus erythematosus. Select all that applies: Your Answer: Antinuclear antibodies (ANA) level above laboratory reference range Anti-double stranded deoxyribonucleic acid (dsDNA) antibody level above laboratory Reference range [or 2-fold the reference range if tested by enzyme-linked immunosorbent assay (ELISA) Anti-Smith (Anti-Sm): presence of antibody to Smith (Sm) nuclear antigen Low complement (C3, C4, or CH50) It is a spectrum of chronic idiopathic inflammatory condition 2. 1 / 1 point A type of inflammatory response where a reaction to sun or light that causes a skin rash to appear or get worse Your Answer: Correct Malar Rash Discoid Rash Serositis Photosensitivity 3. 1 / 1 point A 26-year-old woman has been diagnosed with early systemic lupus erythematosus (SLE) involving her joints. In teaching the patient about the disease, the nurse includes the information that SLE is a(n): Your Answer: Correct Hereditary disorder of women but usually does not show clinical symptoms unless a woman becomes pregnant. Autoimmune disease of women in which antibodies are formed that destroy all nucleated cells in the body. Disorder of immune function, but it is extremely variable in its course, and there is no way to predict its progression. Disease that causes production of antibodies that bind with cellular estrogen receptors, causing an inflammatory response. 4. 1 / 1 point Lupus is an infection Your Answer: Correct True False 5. 1 / 1 point A patient with an acute exacerbation of systemic lupus erythematosus (SLE) was hospitalized with incapacitating fatigue, acute hand and wrist pain, and proteinuria. The health care provider prescribes prednisone (Deltasone) 40 mg twice daily. Which nursing action should include in the plan of care? Your Answer: Correct Institute seizure precautions. Reorient to time and place PRN. Monitor intake and output Place on cardiac monitor. 6. 1 / 1 point People do not die from lupus. Your Answer: Correct True False 7. 1 / 1 point Nurse Dakota is making morning rounds, and as she assists the patient to dress, she recognizes that the patient's fingers are white in color and cold to touch. The nurse is correct when she thinks that the condition is Your Answer: Correct Arthritis Arthralgia Raynaud's Phenomenon Seizures 8. 1 / 1 point Nurse Paco is asking for the health history and family health history of the patient. Which among the options does not apply to ask? Your Answer: Correct Have your parents or siblings had lupus or other autoimmune disorders? Have your neighbors been diagnosed with any other medical conditions? What medications and supplements do you take regularly? When did your symptoms begin? Do they come and go? 9. 1 / 1 point A patient reports painful swelling joints with a history of systemic lupus erythematosus (SLE). What kind of prescription medication should the nurse expect? Your Answer: Correct Nonsteroidal anti-inflammatory drug (NSAID) Immunosuppressive agent Antimalarial drug Topical corticosteroid 10. 1 / 1 point When a symptom becomes significantly worse than it was previously is called . Use UPPER-CASE letters, plural or singular form is accepted Your Answer: Correct FLARE 11. 1 / 1 point A client with systemic lupus erythematosus undergoes an entrance assessment by a clinic nurse (SLE). Which cutaneous sign of SLE is most likely to be assessed by the nurse? Your Answer: Correct Urticaria Butterfly-shaped rash Purpura Photosensitivity 12. 1 / 1 point When symptoms are inactive and under control is called . Use UPPER-CASE letters, plural or singular form is accepted Your Answer: Correct REMISSION 13. 1 / 1 point Student nurse John is correct when he stated that the goal of treatment in SLE are Your Answer: Correct Remission of symptoms Prevention of disease flares and organ damage Minimizing drug side effects Flare of symptoms 14. 1 / 1 point Although the exact cause of lupus isn't yet known, which of these are believed to be factors? Your Answer: Correct Inherited gene Exposure to ultraviolet light Estrogen Testosterone A, B, C All of the above 15. 0.75 / 1 point The head nurse assessed the knowledge of the student nurse regarding SLE. The student nurse is correct when stating that the complication of SLE include Your Answer: Partially correct Glaucoma Lung Cancer Inflammation of the kidneys Dislocated shoulders 16. 1 / 1 point Who are the people who are most likely to develop lupus? Your Answer: Correct Men 15 to 45 years of age Women 15 to 45 years of age Men 45 to 70 years of age Women 45 to 70 years of age 17. 1 / 1 point Raynaud syndrome is characterized by all of the following, EXCEPT: Your Answer: Correct Results from vasospasms Caused by exposure to heat Occurs in the hands and feet Causes the hands to turn red, white, or blue 18. 1 / 1 point Patients with lupus taking an antimalarial drug should have which examination before treatment and annually during treatment? Your Answer: Correct Pap test Ear examination Eye examination Colorectal examination 19. 0.67 / 2 points A 20-year-old African-American woman visits the clinic because she had generalized joint discomfort in her hips and knees for the previous five months. During this period, she has also noticed a rash on her nose and cheeks. Her medical history is unremarkable, and she does not suffer from any allergies. Her current temperature is 100.5°F. A physical exam is notable for warmth and swelling in both of the patient’s knees. Lab studies are performed and shown below: • Hemoglobin: 10.7 g/dL • ESR: 43 mm/h • Serum urea nitrogen: 31 mg/dL • Creatinine: 1.9 mg/dL What is the symptom disclosed by the patient that diagnoses the relevance of SLE? Your Answer: Joint pain Malar rash Hemoglobin: 10.7 g/dL ESR: 43 mm/h Serum urea nitrogen: 31 mg/dL Creatinine: 1.9 mg/dL 20. 0 / 1 point Which medication below is used to treat Systemic Lupus Erythematosus decreases inflammation quickly, is not for long-term usage, and can lead to weight gain, susceptibility to infection, diabetes, and osteoporosis? Your Answer: Hydroxychloroquine Prednisone. Azathioprine Belimumab 21. 1 / 1 point You're giving a Systemic Lupus Erythematosus support group information on how to avoid flares. Which statement by a participant requires re-education about this topic? Your Answer: Correct "Emotional stress and illness are triggers for a flare-up." "I always wear large-brimmed hats and long sleeves when I'm outside." "Exercise should be avoided due to the physical stress it causes on the body." "I will make it a priority to receive my yearly influenza vaccine. 22. 1 / 1 point Nurse Schmidt needed further teaching when he stated that this medication could induce lupus. Your Answer: Correct Isoniazid Procainamide Plaquenil Hydralazine. 23. 1 / 1 point On a client with systemic lupus erythematosus, a complete blood cell count is performed. The nurse would suspect that which of the following findings will be reported from this blood test? Your Answer: Correct Increased red blood cell count Decrease of all cell types Increased white blood cell count Increased neutrophils 24. 1 / 1 point How many unique criteria (least) must a patient meet simultaneously or in sequential evaluation to get diagnosed with systemic lupus erythematosus (SLE)? Your Answer: Correct Six Five Three Four 25. 1 / 1 point A patient voices concerns about taking procainamide. States that a friend was recently hospitalized for drug-induced lupus erythematosus. What is your best response? Your Answer: Correct "Procainamide is not typically associated with drug-induced SLE." "If this hasn't occurred yet, there is no continued risk of drug-induced SLE." "Drug-induced SLE generally occurs months to a year after continuous use of this drug." "Drug-induced SLE is a common side effect of medication therapy, particularly this medication." 26. 1 / 1 point It is the chemical markers released by disease-fighting cells to target a foreign body. Your Answer: Correct Autoantibody Antigens Antibody Neutrophils 27. 1 / 1 point A patient is diagnosed with systemic lupus erythematosus (SLE). What neurologic manifestations should the nurse closely monitor? Select all that apply. Your Answer: Correct Stroke Seizures Alopecia Synovitis Psychosis 28. 1 / 1 point A client diagnosed with lupus is experiencing pulmonary interstitial fibrosis. Which classification of lupus should the nurse suspect? Your Answer: Correct Systemic Drug-induced Discoid Cutaneous 29. 0 / 1 point Your immune system is made up of white blood cells that recognize the antigens from the invaders. And your white blood cells create antibodies to mark those invaders as targets for your immune system to destroy them. In autoimmune diseases, your white blood cells mistakenly create antibodies to mark some of your body cells for destruction. As the antibodies attached to your normal cells, white blood cells begin to attack them as if they were foreign. Your Answer: Incorrect 1st statement is correct & 2nd statement is incorrect 1st statement is incorrect & 2nd statement is correct Both statements are correct Both statements are incorrect 30. ? / 0 points State a situation that can arise during your shift to your patient Faustina. Give one appropriate independent nursing action you can do concerning the current condition of your patient. Your Answer: Awaiting score ¶tell patient faustina to drink lots of water. 10/20 If patient is asking on how does SLE affects her life, nurse's reply should be: "You should enjoy your life now with your families, you will be expired soon." "It is hard to tell because the severity and progression of the disease varies. " Using a long-term corticosteroid can manage SLE, but your life span is lessened." "SLE causes death once in a while, you can still plan to have a normal life." Anti-double stranded deoxyribonucleic acid (dsDNA) antibody level above laboratory Reference range [or 2-fold the reference range if tested by enzyme-linked immunosorbent assay (ELISA) Low complement (C3, C4, or CH50). Anti-Smith (Anti-Sm): presence of antibody to Smith (Sm) nuclear antigen Antinuclear antibodies (ANA) level above laboratory reference range. In the clinical management of Systemic Lupus Erythematosus, monitoring should all be considered, but one: Complete Blood Count Physical exam History taking Skin biopsy Patient Lyn is INCORRECT about preventing flares in SLE if she states that: "I should avoid working out as it can cause physical stress." "An influenza vaccine a year is a priority" "When I plan to go outside, I should wear sun hats and long clothes for my protection." "Flare-up can be caused by emotional stress and other illnesses." A malar rash, sometimes called a "butterfly rash" that is formed through sun exposure is a plaque-like rash and it forms a patchy redness and can scar. True False A nurse is educating patient Jen about what she can do to manage fatigue during exacerbation, the patient needs a further teaching if she states that: "I can sit whenever it is possible." "A short period of rest for my joints is good." "Whenever I don't feel extreme tiredness, I can do little exercise." What is/are the main cause(s) of SLE? Unknown What food items to avoid for a patient with SLE? Broccoli Garl ic Turkey Baco n Potatoes Give one goal of treatment for SLE. Prevent progressive loss of organ function. LP: CARE of CLIENTS with AUTO IMMUNE DISORDER Total points18/20 1. Which of the following is recommended for patients with mild or remittent SLE with prominent arthralgias? 1/1 A. Nonsteroidal anti-inflammatory drugs B. Iron supplementation C. Corticosteroids D. Heparin 2. Which of the following is the best screening test to evaluate a patient for possible SLE? 1/1 A. Anti-Ro antibody test B. Antiphospholipid antibody test C. Serum complement levels D. Fluorescent test for ANA 3. What is a lupus flare? 1/1 A Symptoms of a disease cause pain B Symptoms of a chronic disease or condition are suddenly worse C Any form of itching, pain, or fever associated with a disease D None of the above 4. The last word in Systemic Lupus Erythematosus refers to . 1/1 A. redness B. bluishness C. paleness D. purpleness 5. A _ is a butterfly rash characteristic of some people who have SLE. 1/1 A. malar rash B. alar rash C. manard rash D. apoptotic rash 6. Systemic lupus erythematosus (SLE) is a chronic inflammatory connective tissue disorder that can involve joints, kidneys, skin, mucous membranes, and blood vessel walls. Which group of people makes up 70 to 90% of patients with lupus? 1/1 A. People of Asian descent B. Older men C. Women of child-bearing age D. Women over age 50 7. Very active lupus (sometimes called severe lupus) is treated immediately with which of the following? 0/1 A. Heparin or warfarin B. Antimalarial drugs such as hydroxychloroquine C. Nonsteroidal anti-inflammatory drugs (NSAIDs) D. A corticosteroid such as prednisone Correct answer D. A corticosteroid such as prednisone 8. A patient with an acute exacerbation of systemic lupus erythematosus (SLE) is hospitalized with incapacitating fatigue, acute hand and wrist pain, and proteinuria. The health care provider prescribes prednisone (Deltasone) 40 mg twice daily. Which nursing action should be included in the plan of care? 1/1 A. Institute seizure precautions. B. Reorient to time and place PRN. C. Monitor intake and output. D. Place on cardiac monitor. 9. A patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, "I hate the way I look! I never go anyplace except here to the health clinic." An appropriate nursing diagnosis for the patient is: 1/1 A. Activity intolerance related to fatigue and inactivity. B. Impaired skin integrity related to itching and skin sloughing. C. Social isolation related to embarrassment about the effects of SLE. D. Impaired social interaction related to lack of social skills. 10. A client is suspected of having systemic lupus erythematous. The nurse monitors the client, knowing that which of the following is one of the initial characteristic sign of systemic lupus erythematous? 1/1 A. Weight gain B. Subnormal temperature C. Elevated red blood cell count D. Rash on the face across the bridge of the nose 11. The nurse is assigned to care for a client with systemic lupus erythematosus (SLE). The nurse plans care knowing that this disorder is: 1/1 A. A local rash that occurs as a result of allergy B. A disease caused by overexposure to sunlight C. An inflammatory disease of collagen contained in connective tissue D. A disease caused by the continuous release of histamine in the body 12. he nurse is assigned to care for a client admitted to the hospital with a diagnosis of systemic lupus erythematosus (SLE). The nurse reviews the health care provider's prescriptions. Which of the following medications would the nurse expect to be prescribed? 1/1 A. Antibiotic B. Antidiarrheal C. Corticosteroid D. Opioid analgesic 13. The nurse monitors a patient to have Systemic Lupus Erythematosus. Which of the following symptoms is characteristic of this diagnosis? 1/1 A. Increased T-cell count B. Scaley, inflamed rash on shoulders, neck, and face C. Swelling of the extremities D. Decreased erythrocyte sedimentation rate (ESR) 14. In teaching a patient with SLE about the disorder, the nurse knows that the pathophysiology of SLE includes: 1/1 A. Circulating immune complexes formed from IgG autoantibodies reacting with IgG B. An autoimmune T-cell reaction that results in destruction of the deep dermal skin layer C. Immunologic dysfunction leading to chronic inflammation in the cartilage and muscles D. The production of a variety of autoantibodies directed against components of the cell nucleus 15. A female patient's complex symptomatology over the past year has culminated in a diagnosis of systemic lupus erythematosus (SLE). Which of the patient's following statements demonstrates the need for further teaching about the disease? 1/1 A. "I'll try my best to stay out of the sun this summer." B. "I know that I probably have a high chance of getting arthritis." C. "I'm hoping that surgery will be an option for me in the future." D. "I understand that I'm going to be vulnerable to getting infections." 16. The pathophysiology of systemic lupus erthematosus (SLE) is characterized by: 1/1 A. Destruction of nucleic acids and other self-proteins by autoantibodies B. Overproduction of collagen that disrupts the functioning of internal organs C. Formation of abnormal IgG that attaches to cellular antigens, activating complement D. Increased activity of T-suppressor cells with B-cell hypoactivity, resulting in an immunodeficiency 17. A patient with newly diagnosed SLE asks the nurse how the disease will affect her life. The best response by the nurse is: 1/1 A. You can plan to have a near-normal life since SLE rarely causes death B. It is difficult to tell because to disease is so variable in its severity and progression C. Life span is shortened somewhat in people with SLE, but the disease can be controlled with long-term use of corticosteroids D. Most people with SLE have alternating periods of remissions and exacerbations with rapid progression to permanent organ damage 18. During an acute exacerbation, a patient with SLE is treated with corticosteroids. The nurse would expect the steroids to begin to be tapered when serum laboratory results indicate: 1/1 A. Increased RBCs B. Decreased ESR C. Decreased anti-DNA D. Increased complement 19. Teaching that the nurse will plan for the patient with SLE includes: 1/1 A. Ways to avoid exposure to sunlight B. Increasing dietary protein and carbohydrate intake C. The necessity of genetic counseling before planning a family D. The use of no pharmacologic pain interventions instead of analgesics 20. Which type of lupus mainly affects the skin? 0/1 A. Drug-induced lupus B. Systemic lupus erythematosus C. Peripheral lupus erythematosus D. Cutaneous lupus erythematosus Correct answer B.Systemic lupus erythematosus Dopamine 2. 1 point Amyloid plaques are: Your Answer: twisted fibers that build up in neurons. brain messengers that play an important role in memory. deposits of toxic protein aggregates outside the neurons. the main component of a healthy neuron 3. 1 point occur when the cellular material within the cell bodies of neurons becomes replaced by densely packed and twisted strands of protein. Your Answer: amyloid plaques neurofibrillary tangles choline acetyltransferase Lewy bodies 4. 1 point The following drugs are all cholinesterase inhibitors except: Your Answer: Memantine Donepezil Galantamine Rivastigmine 5. 1 point Alzheimer's disease accounts for of all dementia cases age 65 or older. Your Answer: 80-90% 70-80% 50-70% 60-80% 6. 1 point Alzheimer’s disease (AD) is a progressive, reversible, degenerative neurologic disease that begins insidiously. Your Answer: True False 7. 1 point If during a Mini-Mental Status Examination (MMSE) a patient scores between 21 - 24, what does this score indicates in terms of cognitive impairments? Your Answer: Mild cognitive impairment Moderate cognitive impairment Severe cognitive impairment Very severe cognitive impairment 8. 1 point Which of these is the strongest risk factor for developing the Alzheimer's disease? Your Answer: Age Heredity Exposure to toxins None of the above 9. 1 point A client with Alzheimer's disease is awaiting placement in a skilled nursing facility. Which long-term plans would be most therapeutic for the client? Your Answer: Placing mirrors in several locations in the home Placing a picture of herself in her bedroom Placing simple signs to indicate the location of the bedroom, bathroom, and so on Alternating healthcare workers to prevent boredom 10. 1 point Scientists believe that develop in the brain of an Alzheimer's patient, and may be a cause of the disease. Your Answer: Cholesterols Ruptured blood vessels Tumors Plaques and tangles 11. 1 point A nurse caring to a client with Alzheimer's disease overheard a family member say to the client, "if you pee one more time, I won't give you any more food and drinks". What initial action is best for the nurse to take? Your Answer: Take no action because it is the family member saying that to the client Talk to the family member and explain that what she/he has said is not appropriate for the client Give the family member the number for an Elder Abuse Hot line Document what the family member has said 12. 1 point Those who have a parent, brother, sister or child with Alzheimer's are less likely to develop the disease. The risk decreases if more than one family member has the illness. Your Answer: True False 13. 1 point Which of the following will the nurse use when communicating with a client who has a cognitive impairment? Your Answer: Complete explanations with multiple details Pictures or gestures instead of words Stimulating words and phrases to capture the client's attention Short words and simple sentences. 14. 1 point The nurse enters the room of a client with a cognitive impairment disorder and asks what day of the week it is; what the date, month, and year are; and where the client is. The nurse is attempting to assess: Your Answer: confabulation. delirium. orientation. perseveration 15. 1 point A nurse is explaining to a patient the pathophysiology of Alzheimer's disease since they have just been diagnosed. Which of the following is the most correct explanation by the nurse of the pathophysiology of Alzheimer's disease? Your Answer: "Alzheimer's disease is caused by the degeneration of epinephrine neurons and the deficiency of the neurotransmitter epinephrine." "Alzheimer's disease is caused by the degeneration of cholinergic neuron and the deficiency of the neurotransmitter, acetylcholine." "Alzheimer's disease is caused by the degeneration of GABA neurons and the deficiency of the neurotransmitter, GABA." None of the above. 16. 1 point Alzheimer's is an INSIDIOUS disease. This means: Your Answer: That it is terminal That is can be cured That it sneaks up on a person over time. That it only affects the elderly None of the above 17. 1 point When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant? Your Answer: Allow the client to go to bed four to five times during the day Test the cognitive functioning of the client several times a day Provide reality orientation even if the memory loss is severe Maintain consistency in environment, routine, and caregivers. 18. 1 point A client with Alzheimer disease has a disturbed sleep pattern and tends to get up several times during the night. Which nursing diagnoses are appropriate for this client? Your Answer: Impaired memory Impaired social interaction Risk for Aspiration Risk for Injury Self-care deficit Chronic confusion 19. 1 point In clients with a cognitive impairment disorder, the phenomenon of increased confusion in the early evening hours is called: Your Answer: aphasia agnosia sundowning. confabulation 20. 1 point Alzheimer’s disease is the most common form of which of these? Your Answer: Delirium Psychosis Dementia Depression 21. 1 point A nurse is providing teaching to the partner of an older adult client who has Alzheimers disease and has a new prescription for donepezil (Aricept). Which of the following statements by the partner indicates the teaching is effective? Your Answer: This med should increase my husbands appetite This med should help my husband sleep better This medication should help my husbands daily function. This med should increase husbands energy level 22. 1 point Nurse Jericho is working in a long-term care facility is planning care for a client in stage 5 of Alzheimer’s disease. Which of the following interventions should be included in the plan of care? Your Answer: Use gait belt Thicken liquids Provide protective undergarments Assist with ADLs. 23. 1 point The nurse determines that the son of a client with Alzheimer's disease needs further education about the disease when he makes which of the following statements? Your Answer: "I didn't realize the deterioration would be so incapacitating." "The Alzheimer's support group has so much good information." "I get tired of the same old stories, but I know it's important for Dad." "I woke up this morning expecting that my old Dad would be back.". 24. 1 point The client with Alzheimers disease is being assisted with ADLS when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware the client is exhibiting: Your Answer: agnosia apraxia anomia aphasia 25. 1 point Alzheimer's disease is the secondary diagnosis of a client admitted with myocardial infarction. Which nursing intervention should appear on this client's plan of care? Your Answer: Perform activities of daily living for the client to decease frustration Provide a stimulating environment Establish and maintain a routine. Try to reason with the client as much as possible 26. 1 point An elderly client with Alzheimer's disease becomes agitated and combative when a nurse approaches to help with morning care. The most appropriate nursing intervention in this situation would be to: Your Answer: Tell the client family that it is time to get dressed Obtain assistance to restrain the client for safety Remain calm and talk quietly to the client. Call the doctor and request an order for sedation 27. 1 point The nurse would expect a client with early Alzheimer's disease to have problems with: Your Answer: Balancing a checkbook. Self-care measures Relating to family members Remembering his own name 28. 1 point To encourage adequate nutritional intake for a female client with Alzheimer's disease, the nurse should: Your Answer: Stay with the client and encourage him to eat. Help the client fill out his menu Give the client privacy during meals Fill out the menu for the client 29. 1 point Physiologically, what happens to the brain as Alzheimer's progresses? Your Answer: Tissue swells Fluid collects .Many cells die Brain-stem atrophies 30. 1 point The priority of care for a client with Alzheimer's disease is Your Answer: Help client develop coping mechanism Encourage to learn new hobbies and interest Provide him stimulating environment Simplify the environment to eliminate the need to make chores. 31. 1 point A 65 years old client is in the first stage of Alzheimer's disease. Nurse Patricia should plan to focus this client's care on: Your Answer: Offering nourishing finger foods to help maintain the client's nutritional status Providing emotional support and individual counseling. Monitoring the client to prevent minor illnesses from turning into major problems Suggesting new activities for the client and family to do together 32. 1 point How is Alzheimer's diagnosed? Your Answer: Mental-status tests Blood tests Neurological tests All of the above. 33. 1 point Which nursing intervention is most appropriate for a client with Alzheimer's disease who has frequent episodes emotional lability? Your Answer: Attempt humor to alter the client mood Explore reasons for the client’s altered mood Reduce environmental stimuli to redirect the client’s attention. Use logic to point out reality aspects 34. 1 point A patient who has been admitted to the medical unit with new-onset angina also has a diagnosis of Alzheimer's disease. Her husband tells you that he rarely gets a good night's sleep because he needs to be sure she does not wander during the night. He insists on checking each of the medications you give her to be sure they are the same as the ones she takes at home. Based on this information, which nursing diagnosis is most appropriate for this patient? Your Answer: Decreased Cardiac Output related to poor myocardial contractility Caregiver Role Strain related to continuous need for providing care. Ineffective Therapeutic Regimen Management related to poor patient memory Risk for Falls related to patient wandering behavior during the night 35. 1 point Alzheimer's disease is named after Dr. In 1906, Dr. Alzheimer noticed changes in the brain tissue of a woman who had died of an unusual mental illness. Your Answer: Aalois Alzheimer Alllois Alzheimer Allloois Alzheimer Aloois Alzheimer Aloiis Alzheimer Aloiiss Alzheimer Aloiiis Alzheimer Aalois Alzheimer Alllois Alzheimer Allloois Alzheimer Alois Alzheimer Aloois Alzheimer Alouis Alzheimer Alouiis Alzheimer Aloiiss Alzheimer Aloiiis Alzheimer Alios Alzheimer 36. 1 point Alzheimer’s is the most common cause of dementia among older adults. Dementia is the loss of cognitive functioning — thinking, remembering, and reasoning — and behavioral abilities to such an extent that it interferes with a person’s daily life and activities. Your Answer: True False 37. 1 point Alzheimer’s disease (AD) is a progressive, irreversible, degenerative neurologic disease that begins insidiously. Your Answer: True False 38. 1 point Those who have a parent, brother, sister or child with Alzheimer's are more likely to develop the disease. The risk increases if more than one family member has the illness. Your Answer: True False 39. 1 point As the symptoms worsen, it becomes harder for people to remember recent events, to reason, and to recognize people they know. Eventually, a person with Alzheimer’s disease may need full-time assistance. Your Answer: True False 40. 3 points Unavoidable risk factors for Alzheimer’s disease include: Your Answer: Aging Having a family history of Alzheimer’s disease Carrying certain genes Unhealthy lifestyle 41. 3 points Unavoidable risk factors for Alzheimer’s disease include: Your Answer: Aging Unhealthy lifestyle Carrying certain genes Having a family history of Alzheimer’s disease 42. 1 point There is currently no cure, but drugs and other treatments can help slow or ease the cognitive, emotional, and behavioral symptoms and improve the person’s quality of life. Your Answer: True False 43. 4 points Modifiable risk factors for Alzheimer’s disease include: Your Answer: Aging Physical inactivity Having a family history of Alzheimer’s disease Smoking Your score: 88% 15/17 (3 possible points pending) Which nursing action is most likely to promote medication compliance for a patient with Alzheimer's disease who is being discharged home? Your Answer: Correct Using a monthly pill box Having a family member help with medication administration. Have a home health nurse administer medication. Send patient reminders about taking the medication. Explanation: Patients with an altered mental status might forget to take medications. Having a family member remind the patient will ensure medication administration. That is why it is important to educate the SO as well and involve in the creation of care plan in the area. Dr. Manzano has prescribed Donepezil for the client who was diagnosed with Alzheimer’s Disease. Which side effect is the most common associated with this drug? Your Answer: Correct Headache Nausea Restlessness Urinary continence Explanation: Donepezil boosts the effects of acetylcholine, a neurotransmitter that is noticeably depleted in people with Alzheimer's disease. Side effects are more likely at higher dosages and include nausea, vomiting, and diarrhea which may force drug discontinuation Name of Head Nurses Your Answer: Awaiting score Ian Cernechez Atijera, Sheena Clarie Soria Kate, an 85 years old patient comes to the hospital with her daughter. During the physical examination, the patient failed to respond to questions in a logical manner. The gerontology nurse’s action is to: Your Answer: Correct Ask the family member to answer the questions Ask the same questions in a louder and lower voice Determine if the patient knows the name of the current president Rephrase the questions slightly and slowly repeat them in a lower voice Mr. W, a 73 years old male is admitted to the hospital with a diagnosis of Alzheimer’s Disease. One of the symptoms of Alzheimer’s Disease include: Your Answer: Correct Shallow of labile effect Neglect of personal hygiene I don’t know answer to questions Apathetic response to the environment Explanation: Clients with Alzheimer's Disease are often unable to perform the activities of daily living such as eating, bathing, grooming, etc. This is the number one cause of Alzheimer’s Disease for elderly clients Your Answer: Correct Neurons Ruptured blood vessels Plaques and tangles Tumors Explanation: When toxic proteins like beta-amyloid and tau accumulate in the brain, they form plaques and tangles. In the Alzheimer's brain, abnormal levels of this naturally occurring protein clump together to form plaques that collect between neurons and disrupt cell function Mr. W, a 73-year-old client is on the Stage 1 of Alzheimer’s disease. Nurse Ian should plan to focus on Mr. W care on Your Answer: Correct Offering nourishing finger foods to help maintain the client’s nutritional status Providing emotional support and individual counseling Monitoring the client to prevent minor illnesses from turning into major problems. Suggesting new activities for the client and family to do together. Explanation: Clients in the first stage of Alzheimer’s disease are aware that something is happening to them and may become overwhelmed and frightened. Therefore, nursing care typically focuses on providing emotional support and individual counseling. What are the primary presenting symptoms of Alzheimer's disease? Your Answer: Correct Tremors Gait alterations Impaired memory Explanation: Memory loss is the key symptom of Alzheimer's disease. Early signs include difficulty remembering recent events or conversations. As the disease progresses, memory impairments worsen and other symptoms develop. Mr. W, a 73-year-old client with Alzheimer’s Disease became agitated and aggressive when Nurse Claire approaches to help with morning care. The most appropriate nursing intervention in this situation would be to: Your Answer: Correct Tell the client family that it is time to get dressed. Remain calm and talk quietly to the client. Call the doctor to request to sedate the patient. Obtain assistance to restrain the client for safety Explanation: Maintaining a calm approach when intervening with an agitated client is extremely important to prevent triggering the client further. Do not raise your voice, show alarm or offense, or corner, crowd, restrain, criticize, ignore or argue with the person. The calm approach facilitates proper relaying and administration of the needs of the client. Telling the client firmly that it is time to get dressed may increase his agitation, especially if the nurse touches him. Restraints are a last resort to ensure client safety and are inappropriate in this situation. Sedation should be avoided, if possible because it will interfere with CNS functioning and may contribute to the client’s confusion. Nurse Goddy explains that when informing the significant other of a patient being assessed for Alzheimer's disease (AD), the nurse should tell that: Your Answer: Incorrect The most important risk factor for AD is a family history of the disorder. A diagnosis of AD can be made only when other causes of dementia have been ruled out New drugs have been shown to reverse AD dramatically in some patients. The presence of brain atrophy detected by MRI confirms the diagnosis of AD in patients with dementia Explanation: The diagnosis of Alzheimer's disease is based on exclusion. The most major risk factor for the development of Alzheimer's disease is age. Drugs can help delay the progression of Alzheimer's disease, but they don't completely reverse it. Although brain atrophy is common in Alzheimer's disease, it can also occur in other disorders. There is a cure developed to stop the progression of Alzheimer's Disease Your Answer: Correct True False Explanation: Currently, pharmacological interventions are still the only treatment being given to Alzheimer's however, this only delays and do not stop the progression of the disease. All of the following are risk factors of Alzheimer's Disease except? Your Answer: Correct Diabetes Fatigue Vitamin D deficiency Hypertension Explanation: Through the process of ruling out, 1. A growing body of research indicates that AD is linked to diabetes mellitus (DM) and suggests that impaired insulin signaling acts as a crucial risk factor in determining the progression of Alzheimer's disease which makes diabetes a risk factor. 2. Results of our meta-analysis showed that subjects with deficient vitamin D st