Psychiatric Nursing Practice Exam/Test (21-25)

Situation: Mang Juan, age 65 year old, a retired assembly line worker, is admitted to the hospital with a diagnosis of Parkinson's disease.

21. The physician adds Levodopa (Larodopa) to Mang Juan's regimen. Which precaution should the nurse give to Mang Juan during the patient teaching session before the discharge?

a) take a vitamin B6 with each dose of Levodopa
b) eat high protein meals
c) wear elastic stockings to help avoid orthostatic hypotension
d) take levodopa only in an empty stomach

22. Mang Juan symptoms are caused by:

a) cerebral anoxia
b) congenital abnormalities in neonatal transmission in the brain
c) an imbalance in dopamine and acetylcholine
d) an imbalance in glucose and adenosine triphosphate levels

23. Which clinical feature of the disease should the nurse expect to see during admission assessment?

a) muscle flaccidity and lethargy
b) mask like face and shuffling gait
c) dry skin and drooling
d) swayback stance and muscle cramps

24. The physician orders 1 mg of Benztropine p.o. daily for Mang Juan. Which findings suggest a favorable effect from his medication?

a) decreased muscle rigidity
b) decreased dizziness
c) decreased tremors
d) decreased confusion

25. The most important nursing action during Mang Juan's hospitalization is:

a) scheduling routine home visits by the community health nurse
b) scheduling daily sessions with the speech therapist
c) discontinuing all over the counter medications
d) maintaining daily exercise program


ANSWERS AND RATIONALE

21) C
- Levodopa is prescribed to patients with Parkinson's disease to alleviate dopamine deficiency. Its main effect is to decrease muscle rigidity and tremor.

Health Teachings to Patient taking Levodopa include:

• symptoms may not disappear right away as the effect of the drug will be observed only after several weeks or months of treatment. Advise patient to continue taking medication and not to alter dosage with doctor's advise.
• teach the client taking levodopa to limit intake of foods high in Vitamin B6 or pyridoxine such as pork, glandular meats, lamb, veal, legumes, potatoes, oatmeal, wheat germ, avocado, and bananas
• if patient must take Sinemet, levodopa should be withheld for 8 hours first in order to prevent potentiating the effects and side effects of circulating levodopa. Monitor blood pressure.
• if patient will be taking MAO inhibitor such as selegiline (Elderpryl and Deprenyl) at the same time with levodopa, the side effect of levodopa will be aggravated so monitor BP for increasing hypotension, hallucinations and confusion. This synergistic effect of selegiline to levodopa may last for 1 to 2 years
• to reduce the side effect nausea and vomiting, instruct to take it with food
• to prevent orthostatic hypotension, advise to change position slowly. Advise patient to report dizziness experienced while changing positions
• to prevent constipation, increase fluids and engage in regular exercise
• urine and sweat may darken in color. Assure patient this is harmless and there is no need to discontinue medication
• instruct patient to report psychologic reactions such as vivid dreams and hallucination which are also side effects of the drug.

22) C
- Parkinson's disease is characterized by progressive damage to neurons in the cerebral cortex and dopamine receptors located within the basal ganglia that result in imbalance between inhibitory neurotransmitter dopamine and excitatory neurotransmitter acetylcholine.
This imbalance causes problems with voluntary motor function. In Parkinson's disease decreased dopamine activity in the brain results in inability to neutralize acetylcholine and control its effect; excitatory impulses.
The deficiency in dopamine results in generalized degeneration of muscular functioning characterized by tremors at rest, muscle rigidity and akinesia or poverty of movement. The exact cause is unknown but it is common in the elderly. It may be related to certain viruses, drugs, arteriosclerosis, chemical and physical trauma.

23) B
- Assessment Findings in Parkinson's Disease include:

1. Subjective

• shaking of the hands
• fatigue
• problems with coordination
• changes in emotions and judgment
• difficulty speaking
• intolerance of heat
• mild and diffuse muscular pain
• feeling of stiffness and rigidity particularly of the large joints

2. Objective

• tremors (pill-rolling movement of fingers at rest)
• shuffling gait, walking on toes without rhythmic arm movement
• difficulty performing activities of daily living (ADL)
• altered posture and reflexes, difficulty in rising from sitting position, bradykinesia
• drooling
• muscular rigidity
• coordination problems
• sensory abnormalities
• slow, monotone speech
• mask-like facial expression with unblinking eyes
• various autonomic symptoms: lacrimation, constipation, incontinence, decreased sexual capacity, excessive perspiration

24) C
- Anticholinergics are prescribed for Parkinson's to block the excitatory action of acetylcholine. As a result tremors, drooling and rigidity are reduced.

Anticholinergics drugs include:

• Trihexphenidyl (Artane)
• Benztropine (Cogentin)]
• Biperiden (Akineton)
• Procyclidine (Kemadrin)
• Chlorphenoxamine (Phenoxene)

Side effects:

• blurred vision
  
• photophobia
• tachycardia
• urinary retention
• delayed gastric emptying

Patient Instructions:

• emphasize to family and patient the need to provide
• avoid overexposure to heat and sunlight
• during hot weather: drink plenty of fluids, avoid excessive activity
• increased fluid and fiber to reduce constipation
• wear dark glasses for photophobia
• avoid OTC drugs such as antihistamines and sleeping aids that have anticholinergic effect and may interact with the drug
• have an annual eye exam for glaucoma
• discontinue gradually in order to avoid Parkinsonian symptoms when drug is stopped abruptly

25) D
- The main manifestation of patient with Parkinson's disease is impaired physical mobility due to tremors, gait disturbances, and alteration in body positioning.

Exercise is a very important aspect of management in order to maintain proper mobility as much as possible.

• ROM exercises performed twice a day will help prevent contractures and maintain joint mobility
• individualized exercise regimen according to the strength and capacity of the patient in order to maintain flexibility, mobility and muscle function
• ambulation at least 4 times a day to promote independence and self esteem
• teach about use of assistive devices such as canes and walkers to encourage independence and mobility
• teach proper posture and holding hands behind the back to keep spine and neck erect, and keep hands from falling at side
• use chairs with arms to grip
• instruct client to wear low-heeled shoes
• teach client activities that would help to limit postural deformities; to use firm mattress without a pillow, lie in prone position to facilitate proper posture during rest, keep head and neck as erect as possible

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