A client diagnosed with NCD is disoriented and ataxic and wanders. Which is the priority nursing diagnosis?
1. Disturbed thought processes
2. Self-care deficit
3. Risk for injury
4. Altered health-care maintenance
3
Rationale: The priority nursing diagnosis for this client is risk for injury. The client who is ataxic suffers from motor coordination deficits and is at an increased risk for falls. Clients that wander are at a higher risk for injury.
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The nurse is providing discharge teaching for a patient going home on the medication entecavir (Baraclude). What is the priority teaching point for this patient?
A) Take the whole course of the medication as prescribed. B) Take this medication with grapefruit juice. C) Do not stop taking this medication or allow the prescription to run out. D) The patient will take this medication for the rest of his life.
A client, aged 16 years, comes to the crisis clinic. The nurse learns she is being molested by her
uncle. The client told her mother of the uncle's behavior, but the mother accused the daughter of lying. The client's crisis would be classified as a. maturational. b. situational. c. adventitious. d. organic.
In addition to depressed mood or loss of interest in previously enjoyable activities, to be diagnosed as having a major depressive episode a client must exhibit at least four other symptoms, such as:
a. changes in appetite or weight, sleep disturbance, fatigue, and feelings of worthlessness b. flight of ideas, body aches, feeling empty, and overeating c. suicidal ideations, threatening behavior, loss of control, and moderate anxiety d. difficulty making decisions, hallucinations, hyperactivity, and irritability
A tubal ligation cannot be performed safely after a caesarean delivery
Indicate whether the statement is true or false.