Chapter 42
The spouse of the client with Alzheimer's disease is listening to the hospice nurse explaining the client's drug regimen. Which statement by the spouse indicates an understanding of the nurse's instruction?
"Donepezil (Aricept) will treat the symptoms of Alzheimer's disease." Cholinesterase inhibitors (e.g., donepezil) are approved for the symptomatic treatment of Alzheimer's disease. Memantine (Namenda) is indicated for advanced Alzheimer's disease. Rivastigmine (Exelon) is a cholinesterase inhibitor that is used to treat Alzheimer's symptoms. Selective serotonin reuptake inhibitors are antidepressants and may be used in Alzheimer's clients who develop depression. Some clients with Alzheimer's disease experience depression and may be treated with antidepressants such as sertraline.
The nurse's friend fears that his mother is getting old, saying that she is becoming extremely forgetful and disoriented and is beginning to wander. What is the nurse's best response?
"Have you taken her for a check-up?" The mother's symptoms indicate possible Alzheimer's disease or some other physiologic imbalance, and she should be assessed further by a health care provider. The nurse cannot diagnose Alzheimer's disease. The mother's behavior is not normal age-related behavior. Respite care is for caregivers, not for clients.
A female client with newly diagnosed migraines is being discharged with a prescription for sumatriptan (Imitrex). Which comment by the client indicates an understanding of the nurse's discharge instructions?
"I must report any chest pain right away." Chest pain must be reported immediately with the use of sumatriptan. Sumatriptan must be taken as soon as migraine symptoms appear. Remind the client to use contraception (birth control) while taking the drug because it may not be safe for women who are pregnant. Triptans should not be taken with selective serotonin reuptake inhibitors or St. John's wort, an herb used commonly for depression.
A client has been diagnosed with Huntington disease (HD). The nurse is teaching the client and her parents about the genetic aspects of the disease. Which statement made by the parents demonstrates a good understanding of the nurse's teaching?
"If she has children, she'll pass the gene on to her kids." An autosomal dominant trait with high penetrance, such as HD, means that a person who inherits just one mutated allele has an almost 100% chance of developing the disease. Only one defective gene is needed to inherit HD. The client could have inherited it from her father or mother. If the client inherited the gene from her mother, she would live a longer life than other people with the disease. If she inherited the gene from her father, her life would be shorter. Additional testing is not necessary. If the client has HD, then the client has the gene.
The nursing instructor asks the student nurse caring for a client with Alzheimer's disease who has been prescribed donepezil (Aricept) how the drug works. Which response by the nursing student best explains the action of donepezil?
"It delays the destruction of acetylcholine by acetylcholinesterase." By delaying the destruction of acetylcholine, donepezil improves cholinergic neurotransmission in the central nervous system, thus delaying the onset of cognitive decline in some clients. Donepezil is not a serotonin reuptake inhibitor. It is a cholinesterase inhibitor and does not work on the protein beta amyloid, nor does it work on dopamine receptors.
A client receiving sumatriptan (Imitrex) for migraine headaches is experiencing adverse effects after taking the drug. Which adverse effect is of greatest concern to the nurse?
Chest tightness Triptan drugs are contraindicated in clients with coronary artery disease because they can cause arterial narrowing. Clients taking triptan drugs should report angina or chest discomfort to prevent cardiac injury associated with myocardial ischemia. Skin flushing, tingling feelings, and a warm sensation are common adverse effects with triptan medications and are not indications to avoid using this group of drugs.
The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been ordered for treatment of epilepsy. The nurse instructs the client to avoid which beverage?
Grapefruit juice Grapefruit juice can interfere with the metabolism of phenytoin. Apple juice, grape juice, and milk do not interact with phenytoin.
The nurse is caring for a client diagnosed with partial seizures after encephalitis, who is to receive carbamazepine (Tegretol). The nurse plans to monitor the client for which adverse effects?
Headaches dizziness diplopia
A client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place?
Intravenous access Suction equipment at the bedside Siderails up
A client with Parkinson disease is being discharged home with his wife. To ensure success with the management plan, which discharge action is most effective?
Involving the client and his wife in developing a plan of care Involving the client and spouse in developing a plan of care is the best way to ensure success with the management plan. Home health nurse visitations are generally helpful, but may not be needed for this client. Instructing the spouse about the client's needs and providing the spouse with a written plan of care do not reinforce the spouse's involvement and buy-in with the management plan.
A client with early-stage Alzheimer's disease is admitted to the surgical unit for a biopsy. Which client problem is the priority?
Potential for injury related to chronic confusion and physical deficits The priority for interdisciplinary care is safety. Chronic confusion and physical deficits place the client with Alzheimer's disease at high risk for injury. The rest of the problems are usually the result of long-term care and not a priority for a short hospital stay.
The nurse is teaching a client newly diagnosed with migraines about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan?
"I must not miss meals." Missing meals is a trigger for many people suffering from migraines. The client should not skip any meals until the triggers are identified. Monosodium glutamate-containing foods, alcohol, and artificial sweeteners are triggers for many people suffering from migraines and should be eliminated until the triggers are identified.
The home health nurse is checking in on a client with dementia and the client's spouse. The spouse confides to the nurse, "I am so tired and worn out." What is the nurse's best response?
"Make sure you take some time off and take care of yourself too." This response is supportive and reminds the spouse that he or she cannot care for the client when exhausted. Of course, further assessment and planning will be necessary. Questioning the spouse's ability to provide care is not supportive and may offend the spouse. Establishing goals and a daily plan is not a helpful response. A better response would be, "Take one day at a time." Suggesting that the spouse's comment was not nice is judgmental and inappropriate.
The parents of a young child report that their child sometimes stares blankly into space for just a few seconds and then gets very tired. The nurse anticipates that the child will be assessed for which seizure disorder?
Absence Absence seizures are more common in children and consist of brief (often just seconds) periods of loss of consciousness and blank staring, as though he or she is daydreaming. Myoclonic seizures are characterized by brief jerking or stiffening of the extremities, which may occur singly or in groups. Partial seizures are most often seen in adults. Tonic seizures are characterized by an abrupt increase in muscle tone, loss of consciousness, and autonomic changes lasting from 30 seconds to several minutes.
A client newly diagnosed with Parkinson disease is being discharged. Which instruction is best for the nurse to provide to the client's spouse?
Administer medications promptly on schedule to maintain therapeutic drug levels. Administering medications promptly on schedule is a correct statement. The client should be encouraged to do as much as possible on his own. Slow speech rather than loud speech, and small, frequent meals are more effective for the client with Parkinson disease.
A client with a migraine is lying in a darkened room with a wet cloth on the head after receiving analgesic drugs. What does the nurse do next?
Allow the client to remain undisturbed. At the beginning of a migraine attack, the client may be able to alleviate pain with analgesics and by lying down in a darkened room with a cool cloth on his or her forehead. If the client falls asleep, he or she should remain undisturbed until awakening. Assessing the client's vital signs will disturb the client unnecessarily. A cool cloth is helpful for the client with a migraine and does not present enough of a risk that it should be removed. Turning on the lights for a neurologic assessment is not appropriate because light can cause the migraine to worsen.
The wife of a client with Alzheimer's disease mentions to the home health nurse that, although she loves him, she is exhausted caring for her husband. What does the nurse do to alleviate caregiver stress?
Arranges for respite care Respite care can give the wife some time to re-energize and will provide a social outlet for the client. Providing positive reinforcement and support is encouraging, but does not help the wife's situation. Restraints are almost never appropriate and are used only as an absolute last resort. The client with Alzheimer's disease typically is unable to learn improved self-care.
A client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What does the nurse do first?
Assess the need for additional support. The primary goal is to assess the client for the need of additional support during the seizure. Interventions to protect the client from injury, turning the client on the side, and monitoring the client are indicated. After a quick assessment by the nurse, the health care provider must be notified immediately, and intubation by an anesthesiologist, nurse anesthetist, or respiratory therapist may be necessary. Phenytoin (Dilantin) is administered to prevent the recurrence of seizures, not to treat a seizure already underway. Drawing blood or starting an IV is not the priority in this situation.
A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client?
Assessing neurologic status at least every 2 to 4 hours The most important nursing intervention for clients with meningitis is the accurate monitoring and recording of their neurologic status, vital signs, and vascular assessment. The client's neurologic status and vital signs should be assessed at least every 4 hours, or more often if clinically indicated. The priority for care is to monitor for early neurologic changes that may indicate increased intracranial pressure, such as decreased level of consciousness. Decreasing environmental stimuli is helpful for the client with bacterial meningitis, but is not the highest priority. Clients with bacterial meningitis report severe headaches requiring pain management, but this is the second-highest priority. Assessing fluid balance while preventing overload is not the highest priority.
A client is being discharged to home with progressing stage I Alzheimer's disease. The family expresses concern to the nurse about caring for their parent. What is the priority for best continuity of care?
Assigning a case manager Whenever possible, the client and family should be assigned a case manager who can assess their needs for health care resources and facilitate appropriate placement throughout the continuum of care. Ensuring all questions are answered and providing a safe environment are necessary for family support, but are not relevant for continuity of care. Referring the family to the Alzheimer's Association is necessary for appropriate resource referral, but is not relevant for continuity of care.
The nurse is caring for a client with advanced Alzheimer's disease. Which communication technique is best to use with this client?
Assuming that the client is not totally confused Never assume that the client with Alzheimer's is totally confused and cannot understand what is being communicated. Choices should be limited; too many choices cause frustration and increased confusion in the client. Rather than waiting for the client to express a need, try to anticipate the client's needs and interpret nonverbal communication. Rather than writing down instructions, provide the client instructions with pictures, and put them in a highly visible place.
The nurse is reviewing the history of a client who has been prescribed topiramate (Topamax) for treatment of intractable partial seizures. The nurse plans to contact the health care provider if the client has which condition?
Bipolar disorder Cases of suicide have been associated with topiramate when it is used in larger doses of 400 mg daily, most often in clients with bipolar disorder. Topiramate is not contraindicated in clients with diabetes mellitus, glaucoma, or hypothyroidism.
A client receiving sumatriptan (Imitrex) for migraine headaches is experiencing adverse effects after taking the drug. Which adverse effect is of greatest concern to the nurse
Chest tightness Triptan drugs are contraindicated in clients with coronary artery disease because they can cause arterial narrowing. Clients taking triptan drugs should report angina or chest discomfort to prevent cardiac injury associated with myocardial ischemia. Skin flushing, tingling feelings, and a warm sensation are common adverse effects with triptan medications and are not indications to avoid using this group of drugs.
A client is admitted into the emergency department with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring?
Classic migraine The client's symptoms match those of a classic migraine. Symptoms of a stroke include sudden, severe headache with unknown cause, facial drooping, sudden confusion, and sudden difficulty walking or standing. A tension headache is characterized by neck and shoulder muscle tenderness and bilateral pain at the base of the skull and in the forehead. Symptoms of a cluster headache include intense, unilateral pain occurring in the fall or spring and lasting 30 minutes to 2 hours.
Which change in the cerebrospinal fluid (CSF) indicates to the nurse that a client may have bacterial meningitis?
Cloudy, turbid CSF Cloudy, turbid CSF is a sign of bacterial meningitis. Clear fluid is a sign of viral meningitis. Increased white blood cells, increased protein, and decreased glucose are signs of bacterial meningitis.
Which is the most effective way for a college student to minimize the risk for bacterial meningitis?
Get the meningococcal vaccine. Individuals ages 16 to 21 years have the highest rates of meningococcal infection and should be immunized against the virus. Adults are advised to get an initial or booster vaccine if living in a shared residence (residence hall, military barracks, group home), traveling or residing in countries in which the disease is common, or immunocompromised due to a damaged or surgically removed spleen or a serum complement deficiency. Avoiding large crowds is helpful, but is not practical for a college student. Taking a daily vitamin is helpful, but is not the best way to safeguard against bacterial meningitis. Taking prophylactic antibiotics is inappropriate because it leads to antibiotic-resistant strains of microorganisms.
A client has Parkinson disease (PD). Which nursing intervention best protects the client from injury?
Monitoring the client's sleep patterns Clients with PD tend to not sleep well at night because of drug therapy and the disease itself. Some clients nap for short periods during the day and may not be aware that they have done so. This sleep misperception could put the client at risk for injury (e.g., falling asleep while driving). Active and passive range-of-motion exercises, muscle stretching, and activity are important to keep the client with PD mobile and flexible. The client with PD should avoid watching his or her feet when walking to prevent falls and should be encouraged to participate as much as possible in self-management, including ADLs. Occupational and physical therapists can provide training in ADLs and the use of adaptive devices, as needed, to facilitate independence.
The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next?
Positions the client on the side. Turning the client on the side during a generalized tonic-clonic or complex partial seizure is indicated because he or she may lose consciousness. Documenting the length and time of seizures is important, but not the first priority intervention. Forcing a tongue blade in the mouth can cause damage. Restraining the client can cause injury.
A client with dementia and Alzheimer's disease is discharged to home. The client's daughter says, "He wanders so much, I am afraid he'll slip away from me." What resource does the nurse suggest?
Safe Return Program The family should enroll the client in the Safe Return Program, a national, government-funded program of the Alzheimer's Association that assists in the identification and safe, timely return of those with dementia who wander off and become lost. The Alzheimer's Wandering Association, National Alzheimer's Group, and Lost Family Members Tracking Association do not exist.
The nurse has received report on a group of clients. Which client requires the nurse's attention first?
Young adult who has experienced four tonic-clonic seizures within the past 30 minutes The young adult client who is experiencing repeated seizures over the course of 30 minutes is in status epilepticus, which is a medical emergency and requires immediate intervention. The adult client who is lethargic and the middle-aged adult client with absence seizures do not require immediate attention; these are not medical emergencies. A fever of 101.9° F (38.8° C) is not a medical emergency and does not require immediate attention.
