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Alzheimer’s Disease (Dementia) NCLEX Nursing Review

Alzheimer’s disease (dementia) NCLEX review for nursing students !

This review will discuss a type of dementia known as Alzheimer’s disease. It’s vital a nurse knows how to provide care with this type of disease.

You will learn the following information in this review:

• What is Alzheimer’s disease?
• Pathophysiology
• Nurse’s Role

Medications

Don’t forget to access the free Alzheimer’s disease quiz when you’re done reviewing this material.

What is Alzheimer’s Disease?

It’s a chronic brain disease that is a type of dementia. It occurs because neurons in the brain lose the ability to communicate and eventually die. This is mainly due to the development of plaques and tangles.

These plaques and tangles lead to a progressive loss of the ability to:

problem solve, communicate, recall memories, perform everyday tasks, and care for one self.

Eventually, as the disease progresses, the person will be completely dependent on someone for care. It is not reversible and no cure is currently available. Medications are available to help manage symptoms.  

Interesting Facts about Alzheimer’s Disease

According to the CDC.gov:

• 5 th leading cause of death among adults 65 or older
• 6.2 million Americans had Alzheimer ’s disease in 2021
• Cases of this disease are expected to increase to 14 million by 2060
• Women are more likely to develop this disease than men (because they tend to live longer).
• Hispanics and African Americans are at a higher risk.
• Signs and symptoms tend to appear after the age of 60 (but it could happen earlier).
• Risk Factors: family history, age, gender, diabetes, heart disease, smoking
• This is a disease that becomes progressively worst and can be organized into stages. Some patients progress slowly through the stages, while others may go fast through them.
• The exact cause of Alzheimer’s disease is not fully understood but plaques and tangles seem to be the common problem.

Therefore, as you can see from the facts above this is a chronic disease that gradually becomes worse until the patient is unable to function. It is very debilitating for the patient and creates a major impact for family members (who tend to be the caregivers) and healthcare workers. If family can’t provide care to the patient, care will be provided in a skilled nursing facility.

As a nurse you will definitely be caring for patients with this disease. So to help us understand how to provide care to a person with Alzheimer’s disease, let’s talk about the pathophysiology.  

Pathophysiology of Alzheimer’s Disease

This disease affects the brain, specifically neurons that make up certain areas of the brain. First let’s review the neuron:

We have billions of neurons in our brain that are always talking to each other and sending messages. This is how we are able to function. To communicate, they send electrical signals and release neurotransmitters at their synapse, which sends a unique message to other nerve cells, muscles, or glands.

The message sent depends on the type of neurotransmitter released. There are many different types of neurotransmitters in the body. As a side note, there are two neurotransmitters I want you to remember: acetylcholine and glutamate . These neurotransmitters are targeted with medications used to treat this disease.

The structure of the neuron is made up of a cell body. This contains the nucleus which gives it structure and helps keep things running smoothly for the neuron.

The dendrites, which remind me of tree branches waiting from something to land on them, receive information for other nerves cells and take that message to the cell body. The axon takes information it receives away from the cell body and to other dendrites of neurons or another structure.

Now, around the neuron are cells that help protect its ability to function. One type of cell is called the microglia. It provides safety to the neuron by keeping it safe from damage by removing dangerous material.

So, in order for the neuron to work, it must be intact and free from anything that can impede communication like tangles or plaques. In Alzheimer’s disease, neurons lose the ability to communicate, thrive, and then die.

Why do they do this?

Development of Plaques and Tangles:

First, let’s talk about plaques:

Beta-amyloid plaques are found in between neurons (outside them).

These plaques are made up of beta-amyloid proteins that form between neurons and result in impediment of communication. How do they get there?

Let’s look at the cell membrane of the nerve cell:

Crossing through the cell membrane is a protein called APP ( amyloid precursor protein ). As it crosses over through the membrane, enzymes from outside and inside the cell membrane cause this protein to breakdown into small pieces of peptides.

Normally, these peptides that have broken off from the APP will be metabolized and removed from outside the neuron. However, in Alzheimer’s disease the enzyme that is helping the beta amyloid peptide break off isn’t working right. Therefore, large strands of beta-amyloid peptides are created. These peptides are not metabolized correctly and start to congregate between neurons creating plaques.

This will cause problems with neuron communication and inflammation occurs, which damages the neuron and it eventually dies. These plaques collect in various parts of the brain and lead to the decline in brain functioning.

Now, outside the neuron (as I pointed out in the neuron section) there are cells that help protect the neuron. One type is called the microglia and its job is to keep the environment of the neuron nice and tidy (so it eats any debris hanging out). When it sees these plaques it causes a major inflammatory response, which makes things worst for the neuron.

Neurofibrillary tangles are found inside the neuron.

These tangles are made up of a protein called Tau . This protein plays a role in providing structural strength to the microtubules in the neuron.

Microtubules play a vital role in helping deliver nutrients throughout the neuron and helps give it shape. However, in Alzheimer’s disease Tau proteins quit working and begin to change. This causes the microtubules to fall apart (which is going to affect how nutrients are delivered within the neuron).

Unfortunately, the Tau proteins start to clump together. This forms neurofibrillary tangles. These tangles will affect how the neuron works inside and will eventually lead it to die. When neurons quit communicating and die, this leads the brain tissue to become smaller called brain atrophy.

NOTE: there is some controversy regarding the tangle theory, so our scientific understanding of Alzheimer’s disease may change as additional research is performed.

Now let’s review the parts of the brain because this will help us understand the signs and symptoms found in a patient with Alzheimer’s disease.

Our brain can be divided into different sections based on their function. These functions of each part of the brain can help us understand why certain signs and symptoms appear with this disease.

During the early parts of this disease, brain changes start to occur before signs and symptoms actually appear.

Alzheimer’s disease tends to start and affect the structures deep in the central part of the brain. For example, the hippocampus is affected early on. This area of the brain is responsible for learning and memory (forming new memories like fact-based memories and spatial memory which helps you navigate around).

Close by this structure and also affected is the entorhinal cortex, which plays a role with understanding time, direction, and memory. In addition, the amygdala, which plays a role with emotional memory, is affected. Therefore, as you can see these structures share the role of some type of memory. This is why usually the first sign of Alzheimer’s disease is related to memory loss.

Later on in the disease, the cerebral cortex is affected. The cerebral cortex is the outside layer in the brain that surrounds the top of the cerebrum. Therefore, we’re talking about a huge part of the brain.

The cerebral cortex is made up of different lobes (frontal, parietal, temporal, and occipital lobes) that are responsible for different brain functions like our emotions, ability to process thoughts and solve problems, plan, reason, and communicate language.  In Alzheimer’s disease these lobes can be affected, which leads to corresponding symptoms in the patient.

Now let’s start talking about the signs and symptoms of this disease. There are some important terms used to describe some signs and symptoms seen in a patient with this disease. You want to know these for exams and in practice.

The helpful thing about these terms, since we are talking about Alzheimer’s disease (which starts with the letter A), is that all these terms start with the letter A and end with ia :

Apraxia: inability to perform a certain motor activities (ex: can’t perform the movements to use a toothbrush or fork)

Aphasia: can’t understand speech or create speech to communicate

Agnosia : can’t recognize everyday objects, people, or interpret their senses (taste, sound, smell etc.)

• Ex: can’t recognize people (forget their spouse or children) or a place, bowel and urine incontinence (don’t understand the sensation to use the bathroom)

Amnesia : memory loss (starts with short and them progresses to long term)

• can’t remember the year or current date (time), can’t tell you what they did that day (early on until the disease spreads they can remember childhood memories but not about a recent memory but as the disease spreads long-term memories will be gone), repeats themselves because they forgot they told you, forgets about important events

Anomia : inability to recall the name of objects…may make up words to call the object

Stages of Alzheimer’s Disease

These signs and symptoms develop over time and progressively get worst. The progression of Alzheimer’s disease can be organized into the following stages:

Preclinical Alzheimer’s Disease:

• Changes occurring in the brain but no symptoms noted….can happen over years.

Mild Cognitive Impairment

• Memory changes that are subtle but doesn’t affect their activities.
• Forgetting things especially recent commitments, new people they’ve met, or conversations, start to get confused on places or time, feels like something isn’t right…can’t think clearly
• Can last for several years

Mild Alzheimer’s (Early-stage):

• Typically when the Alzheimer’s Disease is diagnosed
• Mild forgetfulness that is noticed by others, and it’s starting to affect some parts of their functioning…short-term memory problems (losing objects frequently or can’t remember new material just learned), repeating self or asking the same questions, language problems start (can’t think of the word), mental instability like depression, confusion, insomnia
• Still can function and be independent but during this time patient needs to be planning for the future (end of life care and plans, estate planning etc.)
• Last a couple of years

Moderate Alzheimer’s Disease (Middle Stage):

• Confusion now sets in that affects how the patient can function and they will need help (safety is an issue along with self-care)
• judgement is lapsed: safety an issue, getting lost, wandering, forgetting how to cook or use objects like with hygiene, needs help with bathroom, how to dress depending on the weather, confusing family members, insomnia, mental instability: episodes of anger and anxiety, hallucinations
• Sundowner’s Syndrome: as the day gets closer to evening the patient’s confusion increases with intense periods of agitation and hallucinations
• Patient able to move around and engage in activities (that are simple) but must be monitored.
• Intense time for caregivers because patient must be monitored at all times and requires a lot of care
• Longest stage

Severe Alzheimer’s Disease: (Late Stage)

• Severe symptoms
• Language communication minimal along with motor activities, spends much time in bed or sitting needs
• due to this they are at risk for lung infections like pneumonia
• Needs constant care
• Interacting with the patient still very important, use nonverbal and touch as needed, have calming music on during the day

Testing for Alzheimer’s Decease

As pointed out earlier, the brain in undergoing changes before the patient actually has symptoms. Early detection is key in helping the patient prepare and get treatment (that doesn’t cure) but helps symptoms.

In order for a physician to diagnose this disease they must do investigative work because there is NOT one conclusive test for Alzheimer’s disease at this time. Many different tests are used because other conditions can present as this disease like a brain injury, stroke, or tumor.

Tests can include:

Cognitive assessments (tests thinking, memory, and judgement), mental evaluations, diagnostic imaging, biomarker tests, genetic testing

Diagnostic Imaging: looks at brain changes and rules out any other causes….example: MRI, CT and/or amyloid PET scan (looks for beta amyloid in the brain)

Biomarkers tests: assesses cerebrospinal fluid (CSF) through a spinal tap for beta-amyloid and tau proteins, and recent new blood test that can assess for biomarkers in the blood

Genetic testing: used for research not routinely ordered….Apolipoprotein E (ApoE-4)…a positive result doesn’t necessarily mean a person will develop the disease.  

Nursing Interventions & Treatment for Alzheimer’s Disease

Role: Identifying signs and symptoms of the disease, educating patient and caregivers, helping patient through the stages (understanding how it progresses, what to expect, medications, testing, end of life care), helping caregivers (immense responsibility for caregiver…identify stress, respite care help, navigating through the disease)

The m iddle and severe stage of this disease is when the patient is going to start needing the most help and care. The 7 M ’s can help guide us through our role as the nurse.

Memory: often reorient patient, remind patient and show how to use objects they have forgotten how to use (display signs on objects as reminders), keep tasks simple (they have problems with complicated instructions…causes agitation), don’t belittle the patient for forgetting

Movement (help keep the patient as independent as the disease allows because this helps with motor skills and body strength): maintain routines, incorporate exercises, easy fun games and things that are easy they like to do

Mental Health: keep calm during outbursts and use calm voice, provide with distractions and give time to respond, don’t hurry patient, be aware of Sundowner’s in some patients and prepare (encourage a calm relaxing environment)

Sundowner’s Syndrome triggers:

• exhaustion (needs period of rest)
• low lighting (not enough time in the sunlight)
• medications
• caffeine (limit at night)

Hallucinations of the senses: see, feel, taste and hearing things…keep calm and be understanding to the patient, acknowledge feelings, remove things that may make the hallucinations worse: outside noises, keep areas well-lit to prevent shadows and remove reflective objects

Maintain Safety: poor judgement (no driving, cooking alone or using dangerous objects), as the disease progress tasks need to be very simple and safe

Watch for wandering (patient loses the ability to recognize places and people along with keeping time) can become lost very easily

• watch for signs they are starting to get lost or forget places, taking longer than normal to return from a place or having trouble finding rooms in the house, or talking about going somewhere they use to go all the time or visit someone
• triggers: unfamiliar, crowded places, needing a basic need met like drink/food, use the bathroom, trying to do a routine they have always done before the disease

Interventions for Wandering:

W ear a medical identification bracelet or GPS tracking device (disguised as a watch or placed in the shoe)

A void stressful, unfamiliar places (crowds, loud areas this can confuse and stress the patient which causes wander)

N eeds met: bathroom, food, and liquid needs

D isplay signs that provide cues to the patient: label the rooms of the house on their doors and place reminders or warning signs

E xercise important: needs an organized day that has periods of activities they enjoy (create a safe place for the patient to wander and walk) and rest

R emove assess to doors or windows by keeping them locked with alarms and obscure the locks and alarms, hide keys to car

Maximize communication : as disease progresses patient will start to have more problems with communicating and the nurse will have to tailor how to communicate with patient based on their ability…even in the late stage communication is very important to provide a loving and caring environment

Communication Interventions

P ick one question or instruction step to give at a time (repeating may be necessary)

A void correcting or arguing (intense tones or anger facial expression can cause stress)

T ake time for patient to speak and respond

I dentify yourself directly in front of patient rather than behind (patient may react in a fearful or impulsive way)

E ye contact on eye level rather than standing is important (feels less intimidating to the patient)

N onverbal communication helpful especially in late stage: act out, point, or use images

T alk in a normal tone that is clear and slow (not loud and fast), eliminate outside noises

M edical Needs

Hygiene: regular bathing, grooming, and mouth care,incontinence…needs ample times to use the bathroom, skin care, help with selecting outfits that are easy to put on limit buckles, buttons and weather appropriate (as the disease progresses the patient loses the ability to make judgement calls about hygiene and dressing)

Hydration: loses sense of thirst or can’t effectively tell you they’re thirsty, needs easy access to refreshment (measure how much taking in) and offer variety of hydration (popsicles, smoothies etc.)

Nourishment: forgets to eat, loses interest, trouble swallowing “dysphagia” this can occur as the disease progresses and leads to pneumonia: speech language pathologist to evaluate: may need thickened liquids and soften food consistency

Interventions for Encouraging the Patient to Eat:

don’t overwhelmed with options (serve one food item at a time), healthy options that they patient likes to eat (healthy fats, proteins, vegetables, and fruits, limit sugars, and salts), finger foods that are soft and easy to chew/swallow (issues with use utensils), help patient focus on meal…short attention span so keep environment well-lit, encourage family members to eat with the patient

Needs help with organizing medications and how to take them, may forget to take, or overdose

Meds don’t cure but can help management symptoms of Alzheimer ’s disease:

Cholinesterase Inhibitors

Remember “DR. G”: D onepezil, R ivastigmine, G alantamine

Cholinesterase inhibitors inhibit the enzyme, cholinesterase, from breaking down the neurotransmitter acetylcholine.

Acetylcholine is a neurotransmitter that has many functions with one of them being memory and thinking abilities. Therefore, by preventing the breakdown of this neurotransmitter, more acetylcholine is available for use in the brain.

Patients with this disease may have low levels of acetylcholine because nerve cells like the cholinergic neurons that work with this neurotransmitter don’t work.

Side effects: GI upset (nausea, vomiting, and diarrhea)….give with food, muscle spasms, bradycardia (risk for falls…monitor heart rate)

N-methyl D-aspartate antagonist (NMDA antagonist)

Memantine: this medication is for moderate to severe dementia, may be taken with cholinesterase inhibitors

It affects the neurotransmitter glutamate. This is a neurotransmitter that likes to excite neurons. It does this by working with NMDA receptors to cause calcium to enter the cell that fires up the neuron. This is a normal process that helps us learn and maintain our mood. BUT if that is happening in excess with too much glutamate being made (like what may be happening in Alzheimer’s disease) it can lead to neuron damage and it dies.

NMDA antagonists limit how glutamate can engage the NMDA receptor so too much calcium can’t fire up the neuron and lead to damage.

Side effects: headache, dizzy (falls), constipation (monitor bowel movements)

Aducanumab: new medication given IV infusion about every 4 weeks…. for early stages of Alzheimer’s disease

Decreases beta-amyloid plaques which can help increase cognitive function…needs diagnostic testing to confirm plaques present like spinal tap or amyloid PET scan

Side effects: brain swelling or bleeding (may need brain scans to monitor brain)

References:

Centers for Disease Control and Prevention. (2021, June 22). Alzheimer’s disease. Centers for Disease Control and Prevention. Retrieved June 7, 2022, from https://www.cdc.gov/dotw/alzheimers/index.htm

Center for Drug Evaluation and Research. (2021, June 7). FDA’s decision to approve new treatment for alzheimer’s disease. U.S. Food and Drug Administration. Retrieved June 8, 2022, from https://www.fda.gov/drugs/news-events-human-drugs/fdas-decision-approve-new-treatment-alzheimers-disease

How is alzheimer’s disease treated? National Institute on Aging. (2021, July 8). Retrieved June 8, 2022, from https://www.nia.nih.gov/health/how-alzheimers-disease-treated

Stages of alzheimer’s. Alzheimer’s Disease and Dementia. (n.d.). Retrieved June 7, 2022, from https://www.alz.org/alzheimers-dementia/stages

Tips to make mealtimes easier for people with alzheimer’s. National Institute on Aging. (n.d.). Retrieved June 8, 2022, from https://www.nia.nih.gov/health/infographics/tips-make-mealtimes-easier-people-alzheimers

The truth about aging and dementia. Centers for Disease Control and Prevention. (2019, August 20). The Retrieved June 7, 2022, from https://www.cdc.gov/aging/publications/features/Alz-Greater-Risk.html

U.S. Department of Health and Human Services. (2022, February 17). Blood test can predict presence of beta-amyloid in the brain, new study finds . National Institute on Aging. Retrieved June 8, 2022, from https://www.nia.nih.gov/news/blood-test-can-predict-presence-beta-amyloid-brain-new-study-finds

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Dementia case study with questions and answers

Dementia case study with questions and answers

Common dementia exam questions for medical finals, OSCEs and MRCP PACES

The case below illustrates the key features in the assessment of a patient with dementia or undiagnosed memory decline. It works through history, examination and investigations – click on the plus symbols to see the answers to each question

Part 1: Mavis

• Mavis is an 84-year old lady, referred to you in the memory clinic for assessment of memory impairment. She attends in the company of her son and daughter-in-law.
• On the pre-clinic questionnaire her son has reported a severe deterioration in all aspects of her cognition over the past 12 months.
• The patient herself acknowledges that there have been memory problems, but feels it is just her short term memory that is an issue.

Question 1.

• To begin the history, start broadly. Build rapport and establish both the patient’s view on memory impairment (if any) and the family’s (or other collateral history).
• Patient’s (and collateral) view of memory decline
• Biographical history
• Objective view of memory decline (e.g. knowledge of current affairs)
• Impact of memory decline on day-to-day living and hobbies
• Social history, including safety and driving
• General medical history (especially medications)
• See below for details on these…

Question 2.

• Is it for everything or are specific details missed out/glossed over?
• Try to pin down specific details (e.g. names of people/places).
• At what time in chronological order do things start to get hazy?

Question 3.

• If under 12 years this will lead to additional point being awarded on some cognitive tests
• Ask about long term memories, e.g. wedding day or different jobs
• Then move on to more recent memories, e.g. last holiday

Question 4.

• If your patient watches the news/read newspapers on a regular basis, ask them to recount the headlines from the past few days.
• Be sure to look for specifics to prevent your patient masking memory deficiencies with broad statements. For example: “The government are incompetent, aren’t they?!” should be clarified by pinning down exactly why they are incompetent, for example: “Jeremy Hunt”.
• If they like to read, can they recall plotlines from current books or items from magazines?
• If they watch TV, can they recount recent plot lines from soaps, or formats of quiz shows?

Question 5.

• Ask about hobbies and other daily activities, and whether or not these have declined recently.
• If your patient no longer participates in a particular hobby, find out why: is it as a result of a physical impairment (e.g. arthritis making cooking difficult), or as the result of a loss of interest/ability to complete tasks (e.g. no longer able to complete crosswords/puzzles).
• Once you have a good idea of the memory decline itself, begin to ask about other features. Including a social and general medical history.

Question 6.

• Review their social history and current set-up, and also subjective assessments from both patient and family over whether or not the current arrangements are safe and sustainable as they are.
• Previous and ongoing alcohol intake
• Smoking history
• Still driving (and if so, how safe that is considered to be from collateral history)
• Who else is at home
• Any package of care
• Upstairs/downstairs living
• Meal arrangements (and whether weight is being sustained).
• Of all these issues, that of driving is perhaps one of the most important, as any ultimate diagnosis of dementia must be informed (by law) to both the DVLA and also the patient’s insurers. If you feel they are still safe to drive despite the diagnosis, you may be asked to provide a report to the DVLA to support this viewpoint.

Now perform a more generalised history, to include past medical history and – more importantly – a drug history.

Question 7.

• Oxybutynin, commonly used in primary care for overactive bladder (anticholinergic side effects)
• Also see how the medications are given (e.g. Dossett box)
• Are lots of full packets found around the house?

Part 2: The History

On taking a history you have found:

• Mavis was able to give a moderately detailed biographical history, but struggled with details extending as far back as the location of her wedding, and also her main jobs throughout her life.
• After prompting from her family, she was able to supply more information, but it was not always entirely accurate.
• Her main hobby was knitting, and it was noted that she had been able to successfully knit a bobble hat for her great-grand child as recently as last month, although it had taken her considerably longer to complete than it might have done a few years previously, and it was a comparatively basic design compared to what she has been able to create previously.
• She has a few children living in the area, who would frequently pop in with shopping, but there had been times when they arrived to find that she was packed and in her coat, stating that she was “just getting ready to go home again”.
• She had been helping occasionally with the school run, but then a couple of weekends ago she had called up one of her sons – just before she was due to drive over for Sunday lunch – and said that she could not remember how to drive to his house.
• Ever since then, they had confiscated her keys to make sure she couldn’t drive. Although she liked to read the paper every day, she could not recall any recent major news events.  Before proceeding to examine her, you note that the GP referral letter has stated that her dementia screen investigations have been completed.

Question 8.

• Raised WCC suggests infection as a cause of acute confusion
• Uraemia and other electrolyte disturbances can cause a persistent confusion.
• Again, to help rule out acute infection/inflammatory conditions
• Liver failure can cause hyperammonaemia, which can cause a persistent confusion.
• Hyper- or hypothyroidism can cause confusion.
• B12 deficiency is an easily missed and reversible cause of dementia.
• This looks for space occupying lesions/hydrocephalus which may cause confusion.
• This can also help to determine the degree of any vascular component of an ultimately diagnosed dementia.

Part 3: Examination

• With the exception of age-related involutional changes on the CT head (noted to have minimal white matter changes/small vessel disease), all the dementia screen bloods are reassuring.
• You next decide to perform a physical examination of Mavis.

Question 9.

• Important physical findings that are of particular relevance to dementia, are looking for other diseases that may have an effect on cognition.
• To look for evidence of stroke – unlikely in this case given the CT head
• Gait (shuffling) and limb movements (tremor, rigidity, bradykinesia)
• Affect is also important here and may also point to underlying depression
• Pay attention to vertical gaze palsy, as in the context of Parkinsonism this may represent a Parkinson plus condition (e.g. progressive supranuclear palsy).
• It is also useful to look at observations including blood pressure (may be overmedicated and at risk of falls from syncope) and postural blood pressure (again, may indicate overmedication but is also associated with Parkinson plus syndromes e.g. MSA)

Part 4: Cognitive Testing

• On examination she is alert and well, mobilising independently around the clinic waiting room area.  A neurological examination was normal throughout, and there were no other major pathologies found on a general examination.
• You now proceed to cognitive testing:

Question 10.

• Click here for details on the MOCA
• Click here for details on the MMSE
• Click here for details on the CLOX test

Part 5: Diagnosis

• Mavis scores 14/30 on a MOCA, losing marks throughout multiple domains of cognition.

Question 11.

• Given the progressive nature of symptoms described by the family, the impairment over multiple domains on cognitive testing, and the impact on daily living that this is starting to have (e.g. packing and getting ready to leave her own home, mistakenly believing she is somewhere else), coupled with the results from her dementia screen, this is most likely an Alzheimer’s type dementia .

Question 12.

• You should proceed by establishing whether or not Mavis would like to be given a formal diagnosis, and if so, explain the above.
• You should review her lying and standing BP and ECG, and – if these give no contraindications – suggest a trial of treatment with an acetylcholinesterase inhibitor, such as donepezil.
• It is important to note the potential side effects – the most distressing of which are related to issues of incontinence.
• If available, put her in touch with support groups
• Given the history of forgetting routes before even getting into the care, advise the patient that she should stop driving and that they need to inform the DVLA of this (for now, we will skip over the depravation of liberty issues that the premature confiscation of keys performed by the family has caused…)
• The GP should be informed of the new diagnosis, and if there are concerns over safety, review by social services for potential support should be arranged.
• Follow-up is advisable over the next few months to see whether the trial of treatment has been beneficial, and whether side effects have been well-tolerated.

Now click here to learn more about dementia

Perfect revision for medical students, finals, osces and mrcp paces, …or  click here to learn about the diagnosis and management of delirium.

AI Learning Tool

Rn Dementia Case Study Quiz

Question: A nurse is providing discharge teaching with the caregiver of a client who has Alzheimer’s disease and has a new prescription for memantine. Which of the following instructions should the nurse include in the teaching?

Answer: Provide extra assistance during ambulation to prevent falls.

Question: A charge nurse in a long-term facility is planning care for a client who has Alzheimer’s disease. Which of the following interventions should the nurse include in the care plan?

Answer: Stay within two arm lengths of the client when talking to her.

Question: A nurse is teaching about home safety with the adult daughter of a client who has Alzheimer’s disease and has recently started wandering aren’t the house at night. Which of the following statements by the daughter indicates an understanding of the teaching?

Answer: “I will have new locks installed at the tops of our outside doors.”

Question: A nurse is admitting an older adult client who fell at home and is disoriented by time, place, and person. Which of the following findings should indicate to the nurse that the client is experiencing delirium?

Answer: The client is experiencing rapid mood swings.

Question: A nurse is walking in the hallway with a client who has dementia. The client says, “I just saw the little white dog my father gave me when I was 10! Go get him for me.” Which of the following replies by the nurse illustrates the use of validation therapy?

Answer: “You must have loved your dog. Tell me about him.”

Fundamentals of Nursing NCLEX Practice Quiz (600 Questions)

Welcome to your NCLEX practice questions for fundamentals of nursing. For this nursing test bank set, test your competence on the concepts of nursing fundamentals. This quiz aims to help student nurses develop their critical thinking skills when answering questions related to the fundamentals of nursing.

Fundamentals of Nursing Nursing Test Bank

This section is the practice quiz for fundamentals of nursing that can help you think critically and augment your review for the NCLEX . There are 600+ NCLEX-style practice questions in this nursing test bank. We’ve made a significant effort to provide you with the most informative rationale, so please be sure to read them. Use these nursing practice questions as an alternative for Quizlet or ATI.

Quiz Guidelines

Before you start, here are some examination guidelines and reminders you must read:

• Practice Exams : Engage with our Practice Exams to hone your skills in a supportive, low-pressure environment. These exams provide immediate feedback and explanations, helping you grasp core concepts, identify improvement areas, and build confidence in your knowledge and abilities.
• You’re given 2 minutes per item.
• For Challenge Exams, click on the “Start Quiz” button to start the quiz.
• Complete the quiz : Ensure that you answer the entire quiz. Only after you’ve answered every item will the score and rationales be shown.
• Learn from the rationales : After each quiz, click on the “View Questions” button to understand the explanation for each answer.
• Free access : Guess what? Our test banks are 100% FREE. Skip the hassle – no sign-ups or registrations here. A sincere promise from Nurseslabs: we have not and won’t ever request your credit card details or personal info for our practice questions. We’re dedicated to keeping this service accessible and cost-free, especially for our amazing students and nurses. So, take the leap and elevate your career hassle-free!
• Share your thoughts : We’d love your feedback, scores, and questions! Please share them in the comments below.

Quizzes included in this guide are:

Recommended Resources

Recommended books and resources for your NCLEX success:

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy .

Saunders Comprehensive Review for the NCLEX-RN Saunders Comprehensive Review for the NCLEX-RN Examination is often referred to as the best nursing exam review book ever. More than 5,700 practice questions are available in the text. Detailed test-taking strategies are provided for each question, with hints for analyzing and uncovering the correct answer option.

Strategies for Student Success on the Next Generation NCLEX® (NGN) Test Items Next Generation NCLEX®-style practice questions of all types are illustrated through stand-alone case studies and unfolding case studies. NCSBN Clinical Judgment Measurement Model (NCJMM) is included throughout with case scenarios that integrate the six clinical judgment cognitive skills.

Saunders Q & A Review for the NCLEX-RN® Examination This edition contains over 6,000 practice questions with each question containing a test-taking strategy and justifications for correct and incorrect answers to enhance review. Questions are organized according to the most recent NCLEX-RN test blueprint Client Needs and Integrated Processes. Questions are written at higher cognitive levels (applying, analyzing, synthesizing, evaluating, and creating) than those on the test itself.

NCLEX-RN Prep Plus by Kaplan The NCLEX-RN Prep Plus from Kaplan employs expert critical thinking techniques and targeted sample questions. This edition identifies seven types of NGN questions and explains in detail how to approach and answer each type. In addition, it provides 10 critical thinking pathways for analyzing exam questions.

Illustrated Study Guide for the NCLEX-RN® Exam The 10th edition of the Illustrated Study Guide for the NCLEX-RN Exam, 10th Edition. This study guide gives you a robust, visual, less-intimidating way to remember key facts. 2,500 review questions are now included on the Evolve companion website. 25 additional illustrations and mnemonics make the book more appealing than ever.

NCLEX RN Examination Prep Flashcards (2023 Edition) NCLEX RN Exam Review FlashCards Study Guide with Practice Test Questions [Full-Color Cards] from Test Prep Books. These flashcards are ready for use, allowing you to begin studying immediately. Each flash card is color-coded for easy subject identification.

Recommended Links

An investment in knowledge pays the best interest. Keep up the pace and continue learning with these practice quizzes:

• Nursing Test Bank: Free Practice Questions UPDATED ! Our most comprehenisve and updated nursing test bank that includes over 3,500 practice questions covering a wide range of nursing topics that are absolutely free!
• NCLEX Questions Nursing Test Bank and Review UPDATED! Over 1,000+ comprehensive NCLEX practice questions covering different nursing topics. We’ve made a significant effort to provide you with the most challenging questions along with insightful rationales for each question to reinforce learning.

38 thoughts on “Fundamentals of Nursing NCLEX Practice Quiz (600 Questions)”

Hello. For Quiz number 2, number 75: It will still mark as wrong even though you chose the right answer which is letter C. Other than that, this website is really helpful. ❤️

Thanks for letting us know. We have corrected the item.

This is perfect

Thanks for all

for quiz #5 question 7 is marking the correct answer wrong

VERY GOOD LEARNING MODULE AND USEFUL FOR UPDATING THE KNOWLEDGE IN NURSING FIELD

In Fundamentals of Nursing NCLEX Practice Questions Quiz #1: 75 Questions, question number 8 asks: Kubler-Ross’s five successive stages of death and dying are: The correct answer is missing a coma, making it incorrect. C. Denial, anger, bargaining, depression acceptance

Hi, can i clarify quiz #7 Question 12: The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is most appropriate for the nurse?

Your correct answer is: B. Do nothing since this is an expected finding.

But it should be intermittent, right? : D. Check for an air leak because the bubbling should be intermittent.

B is correct because it talks about suction chamber, contiuous gentle bubbling. You can also check it here https://youtu.be/WfoXkJM6XHw .

Thank you so much for this educating guide and stepdown Nurse Matt Vera

its help me a lot to practice my skill and comprehension and analyzing the situation

you all are the best

Thank you, Matt Vera. I need to pass the NCLEX test.

Question 72 option B. Fresh food and whole-wheat toast is it suppose to say fresh fruit??

Wow! This site is superb Well done Matt Vera Keep it up. High five✋

Quiz 2 Question 45: The order for examining the abdomen is incorrect. First you inspect, the asculate. Why? percussion or palpating the abdomen before asculating ensures that the examiner is listening to undisturbed bowel sounds. This is different from the rest of the body,

Hello, Q2-45 asks for the assessment technique for all body systems “EXCEPT” the abdomen.

Do you not provide the answer and the explanation of each question anymore?

How soon will the performance issues be rectified??

Hi Anna, hopefully, this week. We’re just waiting for guidance from our developers.

Hey Matt can you take a look at Fundamentals of Nursing NCLEX Practice | Quiz #5 question 29. It indicates a rectal examination and all the answers are urine related? Thanks

Hi Tony, yes, because the question is asking about prostate cancer and a digital rectal exam (DRE) is a test to palpate the prostate for enlargement or masses.

How can i save my answers when I haven’t finished the quiz?

Sorry but we don’t have that function. You can click on the Quiz Summary > Finish Quiz anytime and evaluate your answers. Next time you visit, simply continue on the item where you left off.

Hi, set 2 question 57 put all rails up . Is that considered as a restraint for the patient?

Hello, I don’t understand quiz 3 number 8 question. I answered B because except to remove resident flora, yet the answer is wrong

Hello, the answer “A” is correct. It says “expected” not except.

Hi, in question no. 45 about abdominal assessment. I answered inspection, auscultation, percussion, palpation in order, but I was marked wrong.

Hi Aiko, kindly read the question again. ;)

sorry, my bad. thank you.

Inspection palpatio percussion auscultation

I think that this quiz is excellent. Those who pass should receive a certificate of achievement.

A patient is catheterized with a #16 indwelling urinary (Foley) catheter to determine if:

A. Trauma has occurred. B. His 24-hour output is adequate. C. He has a urinary tract infection. D. Residual urine remains in the bladder after voiding.

THE answer says C. Should that say His 24- hour output is INADEQUATE because if it is adequate he would not need a foley correct?

Very informative question, content and website!!! Thank you!

These are so helpful! Thank you! There are two questions where I believe the correct option is stated incorrectly. Question 21 states “ His 24-hour output is adequate,” it should be “inadequate.” Quest 71 states “ Fresh Food and Whole Wheat Toast,” it should be “Fresh Fruit.”

Are the links working? every time I click on a link, it cycles and then brings me back to the same page so I don’t understand. I clicked on all the quizzes and the 600 question book but I’m not being brought to any questions so I’m just confused as to why I’m not getting to any questions when I’m clicking the links.

Hi Sharell, the links do work but open on a new tab/window.

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KeithRN Clinical Reasoning Case Studies

Prepare students for nextgen nclex and professional practice..

NextGen / Skinny / Unfolding

Heart Failure

Acute coronary syndrome, gastroenteritis, ob hemorrhage, schizophrenia.

All KeithRN Clinical Reasoning Case Studies (CRCS) have been completely revised with new scenarios, clinical data, and a unique interactive format that simulates clinical realities with patient data that unfolds – just like clinical practice.

Each case study uses a consistent framework of open-ended questions with rationale so students can practice clinical decision-making and faculty can evaluate student thinking.

NEW KeithRN Clinical Judgment Rubric!

Nurse educators must create a curriculum that ensures students develop expected levels of clinical judgment to pass the NCLEX and provide safe patient care after graduation. Use KeithRN Clinical Reasoning Case Studies and score students’ performance with a powerful tool that quantitatively measures and assesses students’ clinical judgment skills.

Sign up to receive a free KeithRN NextGen Reasoning Case Study, the new KeithRN Clinical Judgment Rubric, a scoring sheet, and a faculty guide.

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Three Case Study Levels

The three complementary levels of KeithRN CRCS (NextGen-Skinny-Unfolding Reasoning) integrate the nursing process and the four clinical reasoning processes of noticing, interpreting, responding, and reflecting of Tanner’s Clinical Judgment Model (CJM).

NextGen Reasoning

This innovative format replicates the essence of an NGN six-question unfolding case study using open-ended responses with a rationale for each response to evaluate student thinking. Each topic has a student version to post responses and a separate medical record. Suitable for all levels.

Interested in learning more? Watch a demonstration!

Skinny reasoning.

Builds on Nextgen Reasoning with twenty open-ended clinical reasoning questions providing a concise, immersive patient care simulation. Students benefit from integrated assessment images and audio files of breath and heart sounds that replicate practice realities. Suitable for all levels.

Unfolding Reasoning

The most in-depth level expands on Skinny Reasoning by adding additional open-ended questions on dosage calculation, priority setting, and an unfolding change of status requiring the student to determine the current priority and plan of care, simulating a full patient day . Suited for advanced students.

Case Study Levels

Compare the three levels of KeithRN Clinical Reasoning Case Studies: NextGen, Skinny, and Unfolding Reasoning.

Purchase a Think Like a Nurse Membership and never pay for another case study.

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