Which of the following is considered a primary nursing diagnosis for a client with a dissociative disorder?
a. Self-esteem, low
b. Personal identity, disturbed
c. Role performance, ineffective
d. Anxiety
B
Although all of the nursing diagnoses listed are related to dissociative disorders, "Personal identity, disturbed" is the only one listed that is a primary nursing diagnosis for these disorders.
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A 78-year-old male patient has been admitted to your unit with neurological deficits of unknown origin. The nurse caring for this patient knows that dulled tactile sensation in this patient is a normal finding
What could this dulled tactile sensation cause? A) Abnormal identification of personal belongings B) Heightened sense of touch C) Confusion about body position D) Heightened sense of location
The nurse is completing the evaluation phase of the nursing process. What actions should the nurse perform that would be comparable to using the research process?
1. Analyzing results 2. Reporting findings 3. Conducting analysis 4. Conducting literature review 5. Identifying a research question
The nurse is caring for a neonate with a suspected tracheoesophageal fistula. What should nursing care include?
a. Feed glucose water only. b. Elevate the patient's head for feedings. c. Raise the patient's head and give nothing by mouth. d. Avoid suctioning unless the infant is cyanotic.
A client with increased intracranial pressure (ICP) is being repositioned by the nurse with the help of the family members present. Of the following, which interventions are appropriate for the nurse to teach the family? (Select all that apply
) 1. Clients with ICP should remain in a stationary position. 2. The family should use slow, gentle movements when repositioning the client. 3. The client should be returned to supine position. 4. The client should be repositioned every hour. 5. The head of the bed should be elevated.