NR 547 Differential Diagnosis Week 6 Exam Review: Questions and Answers, Exams of Nursing

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NR 547 Differential Diagnosis

Week 6 Complete | Exam Review |

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NR 547 Differential Diagnosis Week 6

Complete | Exam Review | Questions

and Answers 100% Pass | Graded A+

Neurocognitive disorders - Answer>> delirium and dementia Dementia - Answer>> -a group of symptoms that mainly affects memory, cognition and social interactions, and the ability to do everyday tasks. -Symptoms start gradually often with no clear beginning, and are usually permanent. -Most dementias are caused by neurodegenerative diseases, most commonly Alzheimer's disease, Lewy body dementia and frontotemporal dementia

• clumps of abnormal proteins to build up inside neurons, damaging them, and causing them to slowly degenerate and die -vascular dementia is another common cause of progressive dementia
• brain damage occurs when the blood supply to the neurons is reduced or blocked, again causing them to malfunction or die -Cognitive Symptoms: Difficulty with complex tasks, Difficulty planning and organizing, Loss of coordination -Psychological symptoms: Personality changes, Inappropriate behaviour, Paranoia, Fear, anxiety, anger or depression. Delirium - Answer>> ACUTE SUDDEN CHANGE IN MENTAL STATE -typically begins suddenly with a noticeable start point. -mainly affects attention, and often resolves after a few days or weeks, although it can last longer. -acute, transient, and usually reversible brain malfunction -thought to be brought on by multiple neurotransmitter imbalances

• earliest areas affected temporal lobe (learning & memory)
• as it spreads goes to frontal lobe (thinking & planning)
• then more temporal (speaking & communicating)
• then parietal lobe (sense of where body is in relation to objects around you)
• severe & late Alzheimer's disease, plaques & tangles spread throughout most of cortex, brain shrinks (atrophy) dramatically (atrophy primarily affects hippocampus and cerebral cortex) Vascular dementia - Answer>> -20-30% of dementia cases -lack in blood supply to the brain -changes
• suddenly (stroke)
• gradually (small vessels) -risk factors
• similar to heart problems
• smoking
• high BP
• no exercise
• obesity
• poor diet Lewy body dementia - Answer>> -10-25% of dementia cases -abnormal protein structures forming inside neurons (lewy bodies)
• alpha synuclein protein = lewy bodies -lewy bodies can be found it ppl with alzheimers & parkinsons too
• ppl with parkinsons can develop parkinsons later on -symptoms
• thinking & memory
• movements & trembling
• hallucinations
• physically acting out dreams Parkinsons disease dementia - Answer>> affects motor control and mental functions

-lewy bodies found in ppl with parkinsons disease, leads to dementia Frontotemporal dementia - Answer>> -Frontal lobe damage

• spacial orientation -Temporal lobe damage
• speech other causes of dementis - Answer>> -alcohol misuse -repeated head injuries -can have more than one type of dementia present risk factors for dementia - Answer>> -Age
• more common after 80 -family hx
• genetic factors (risk/deterministic genes)
• environmental factors -down syndrome -head trauma -heart trauma Risk gene that has strongest association with developing Alzheimer's - Answer>> apolipoprotein E-E
• APOE-E
• factor in 20-25% of alzheimer's cases Deterministic genes for alzheimer's - Answer>> mutation in any 3 genes can cause early onset alzheimers (before 65) due to a build up of amyloid plaques -Amyloid Precursor Protein (APP) -Presenilin 1 (ps-1) -Presenilin 2 (ps-2) Stages of Alzhimer's disease - Answer>> 3 stage model

-stage 5: early dementis to moderate alzheimer's diease, cognitive decline more drastic, lasts 1.5 years -stage 6: moderatly severe alzheimer's disease, help with basic daily tasks, lasts 2.5 years -stage 7: final stage, speech severely limited, decline in basic abilities, movement abilities affected Diagnosis of dementia and Alzheimer's disease - Answer>> - Patient History -Physical Exam -neurological eval -neuropsychological test

• MMSE: scores 20-24 mild dementia, 13-20 moderate, < severe dementia
• mini-cog test -Psychiatric evaluation -Brain scans
• CT scans
• MRI
• reason for brain scans: ID larger masses, differential diagnosis, monitor disease progression, research purposes Other conditions that can cause dementia like symptoms - Answer>> anemia depression infection diabetes kidney disease etc. Treatment of dementia and Alzheimer's disease - Answer>> No Cure -Medications lesson symptoms -meds target neurotransmitters:
• acetylcholine

• glutamate -Cholinesterase Inhibitors -Memantine Cholinesterase Inhibitors - Answer>> acetylcholine neurotransmitter -helps neurons communicate Acetylcholinesterase -breaks down acetylcholine CHOLINESTERACE INHIBITORS -stop acetylcholinesterase from breaking down acetylcholine
• allowing more acetylcholine to build up, helping neurons communicate -delay worsening dementia symptoms for 6-12 months
• for about 1/2 of patients -side effects: N/V, loss of appetite Medication: -Donepezil (Aricept) -Rivastigmine (Exelon) -Galantamine (Razadyne, Razadyne ER) Memantine - Answer>> Glutamate -excitatory neurotransmitter -normal levels: learning & memory -too high: toxic (excitotoxicity)
• cell too stimulated, may die -Memantine blocks NMDA receptor for glutamate, keeping channel closed so too many ions do not get in so cell doesn't get excitotoxicity -used to tx moderate to severe alzheimer's disease -often taken with cholinesterase inhibitors -side effects: headache, confusion, dizziness Medication:

Galantamine (Razadyne, Razadyne ER) - Answer>> -elevating acetylcholine (Ach) in the cerebral cortex, modulating the nicotinic Ach receptors to increase Ach release from existing presynaptic nerve terminals, increases glutamate and serotonin levels -Side effects: GI symptoms, headache, dizziness, fatigue -Precautions:

• NSAID use
• GI bleed
• asthma or COPD
• concurrent use with medications that slow or decrease heart rate -Contraindications
• severe hepatic impairment
• severe renal impairment -Pearls
• two major metabolizing enzymes CYP3A4 and CYP2D increase galantamine concentrations or reductions in clearance and anticholinergic side effects when given concurrently with inhibitors of these enzymes Memantine (Namenda) - Answer>> -prevents glutamate, an excitatory neurotransmitter, from binding at the receptor site.
• NMDA receptors control activity throughout the brain by regulating how much calcium enters the nerve cell -Side effects: GI symptoms, urinary freq, confusion, dizziness, headache, cough -Precautions:
• concurrent use with (amantadine, rimantadine, ketamine, or dextromethorphan)
• severe hepatic impairment
• severe renal impairment
• medications or conditions that increase the pH of the urine -Pearls:

• used as monotherapy or in conjunction with ChEIs; when given with ChEIs, fall precautions are required and driving is forbidden due to delayed reactions.
• Minimal inhibition of CYP450 enzymes CYP1A2, CYP2A6, CYP2C9, CYP2D6, CYP2E1, and CYP3A4 occurs, which means there are no pharmacokinetic interactions with medications metabolized by these enzymes Cognitive Domains - Answer>> Complex attention Executive function Learning and memory Language Perceptual motor Social cognition cognitive domain impairment: Complex attention - Answer>> - easily distracted -difficulty with mental calculations and multitasking cognitive domain impairment: Executive function - Answer>> - unable to complete complex projects or solve problems -difficulty with instrumental activities of daily living (bills and pills) and making decisions cognitive domain impairment: Learning and memory - Answer>> frequent reminders needed, recent memory impaired cognitive domain impairment: Language - Answer>> -difficulties with expressive or receptive language -word-finding difficulty cognitive domain impairment: Perceptual motor - Answer>> difficulty with navigating familiar environments or using complex tools (carpentry, sewing)

the corner of his room were people standing over him, watching him breathe. He was unable to be reoriented, became agitated, and required soft wrist restraints for safety. In the morning interview, Pete is alert, oriented, pleasant, and cooperative. He complains that he has not had a good night's sleep since before his surgery, and states that last night he asked for and was given a "sleeping pill." Review of his electronic medical record (EMR) confirms a as needed (PRN) dose of zolpide - Answer>> F13.221- moderate delirium due to sedative Rationale: Pete meets diagnostic criteria for medication-induced acute hyperactive delirium due to the administration of zolpidem. Clinical Presentation: Mild and Major NCDs - Answer>> NCD, or dementia, are chronic and progressive processes characterized by cognitive deficits in language, speech, memory, and a decline in motor skills -often accompanied by a decline in emotional control, social behavior, or motivation -Differentiation between mild and major disorders is a continuum

• PMHNP must conduct a thorough functional assessment to determine the level of impairment
• Both types of NCD may present with or without concurrent behavioral disturbance
• Major NCD may be further classified as mild, moderate, or severe, based on the level of impairment. Lisheng is a 77-year-old who lives independently. She presents with her daughter to the clinic. Her daughter has concerns about her mother's memory and functioning. She reports that in the past 12 months, Lisheng has become increasingly forgetful and does not remember what she had for breakfast or what she did the prior day. Lisheng still drives but admits that she has gotten "turned around" a few times when driving to familiar places, especially in the evening. Lisheng's daughter has begun

managing the household finances, as Lisheng missed several payments on the mortgage and utilities. Her medical history includes hypertension. She does not have a psychiatric history. Based on the DSM-5-TR (APA, 2022) criteria, which of the following is the most appropriate criteria for Lisheng? major neurocognitive disorder mild neurocognitive disorder - Answer>> major neurocognitive disorder Rationale: Lisheng meets the criteria for major neurocognitive disorder. Both mild and major neurocognitive disorders involve a significant decline in cognitive function; however, cognitive deficits that interfere with independence, such as difficulty paying bills or managing medications, meet the criteria for major neurocognitive disorder. Based on DSM-5-TR (APA, 2022) criteria and the information provided, which of the following is the most appropriate classification for Lisheng's behavioral symptoms and severity? mild - with behavioral disturbance mild - without behavioral disturbance moderate - with behavioral disturbance moderate - without behavioral disturbance severe - with behavioral disturbance severe - without behavioral disturbance - Answer>> mild - without behavioral disturbance Rationale: The classification of severity and behavioral symptoms for Lisheng is mild without behavioral disturbance. Lisheng presents with difficulties with instrumental ADLs, such as managing money and driving, consistent with mild severity of NCD. Neither she nor her daughter indicates any behavioral disturbance, such as apathy, depression, or agitation.

(developmental age 1). Can no longer walk (developmental age 1). Can no longer sit up without assistance (developmental age 6- 10 months). Can no longer smile (developmental age 2- months). Can no longer hold head up by self (developmental age 1-3 months) Clinical Presentation: Other Mild and Major NCDs - Answer>> Additional diagnoses may be considered as differentials for a client with cognitive impairment -delirium -depression -schizophrenia -head trauma

• place the client's health and safety in immediate danger and, if unrecognized, may result in poor outcomes. Tonia is a 66-year-old who presents with memory difficulty. She states she can't remember anything for longer than a few minutes. She also states that she is having difficulty making complex decisions. She also "doesn't want to do anything anymore." She has stopped attending her exercise class and lunch bunch social club because she no longer has an interest in these activities. She feels "down" every day. Her symptoms began 6 weeks ago, and she has never experienced anything like this. Which of the following diagnoses is most appropriate for Tonia? Major depressive disorder Vascular neurocognitive disorder NCD with Lewy bodies Frontotemporal neurocognitive disorder Neurocognitive disorder due to Parkinson's disease Mild neurocognitive disorder due to traumatic brain injury - Answer>> Major depressive disorder

Rationale: Tonia is most likely experiencing major depressive disorder (MDD). The hallmark features that indicate MDD are depressed mood or loss of interest in usual activities. Although memory difficulties and loss of concentration are common with MDD, they are not predominant features. Daron is a 72-year-old who presents with complaints of memory changes. He states he often walks into a store and forgets why he is there. He reports that he frequently struggles to find the right word to complete a sentence. He endorses difficulty in organizing his monthly finances, although he has not missed any bill payments. He states that he has also been feeling "down" lately. His past history includes hypertension and carotid endarterectomy. Which of the following diagnoses is most appropriate for Daron? Major depressive disorder Vascular neurocognitive disorder NCD with Lewy bodies Frontotemporal neurocognitive disorder Neurocognitive disorder due to Parkinson's disease Mild neurocognitive disorder due to traumatic brain injury - Answer>> Vascular neurocognitive disorder Rationale: Daron's symptoms indicate a possible diagnosis of mild vascular neurocognitive disorder. He presents with memory loss, difficulty in executive function, and feelings of depressed mood, which are frequently associated with vascular NCD. He has cardiovascular risk factors, including hypertension and a past vascular intervention. The PMHNP should ask about symptoms of TIA or CVA, and imaging studies should be conducted to confirm the diagnosis. Trent is a 75-year-old who presents with changes in cognition. He states that there are times that he cannot follow a TV show or

Vascular neurocognitive disorder NCD with Lewy bodies Frontotemporal neurocognitive disorder Neurocognitive disorder due to Parkinson's disease Mild neurocognitive disorder due to traumatic brain injury - Answer>> Frontotemporal neurocognitive disorder Rationale: Cassie's symptoms are consistent with frontotemporal NCD. Hallmark features include behavioral disturbances such as impulsivity, socially inappropriate behavior, hoarding, or apathy; personality changes; and decline in language abilities. Memory is typically intact. Frontotemporal NCD presents at an earlier age than many other forms of NCD. Imaging studies should be conducted to rule out other forms of NCD; frontal lobe atrophy is commonly seen on the CT scan. Dae is a 72-year-old who presents with complaints of increasing memory loss; he is having difficulty remembering things that happened recently. He states that his wife has started preparing his medications after he missed a few doses. He also complains of apathy and daytime sleepiness. Walter was diagnosed with Parkinson's disease three years ago; he has experienced motor symptoms, but the cognitive symptoms are new to him. Which of the following diagnoses is most appropriate for Dae? Major depressive disorder Vascular neurocognitive disorder NCD with Lewy bodies Frontotemporal neurocognitive disorder Neurocognitive disorder due to Parkinson's disease Mild neurocognitive disorder due to traumatic brain injury - Answer>> Neurocognitive disorder due to Parkinson's disease Rationale: Since Dae has an existing diagnosis of Parkinson's disease, he may meet the criteria for NCD due to Parkinson's

disease. In addition to memory loss and decreased executive functioning, symptoms often include apathy, depressed mood, visual hallucinations, and daytime sleepiness. Isaiah is a 28-year-old who presents with difficulty concentrating. He states that he cannot follow conversations when more than one person is talking, and he is having problems at work completing multi-step tasks. He endorses feelings of irritability. He was involved in a motor vehicle crash two days ago; he hit his head on the windshield and briefly lost consciousness. He was treated and released from the emergency department after the crash. Which of the following diagnoses is most appropriate for Isaiah? Major depressive disorder Vascular neurocognitive disorder NCD with Lewy bodies Frontotemporal neurocognitive disorder Neurocognitive disorder due to Parkinson's disease Mild neurocognitive disorder due to traumatic brain injury - Answer>> Mild neurocognitive disorder due to traumatic brain injury Rationale: Isaiah meets diagnostic criteria for mild NCD due to traumatic brain injury; he sustained a head injury with loss of consciousness and his symptoms of difficulty with complex and sustained attention began shortly after the injury. Emotional disturbances, such as irritability, frustration, or anxiety are common. Mild NCD due to traumatic brain injury typically resolves within a few weeks to months after the injury. causes of neurocognitive disorders include: - Answer>> Alzheimer's disease frontotemporal lobar degeneration Lewy body disease