A nurse writes the following nursing diagnosis for a patient with Alzheimer's: Disturbed Thought Processes related to Alzheimer's disease as evidenced by incoherent language. Which part of this diagnosis is considered the problem statement?
A) disturbed thought processes
B) related to
C) Alzheimer's disease
D) incoherent language
A
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A patient underwent an open bowel resection 2 days ago and the nurse's most recent assessment of the patient's abdominal incision reveals that it is dehiscing. What factor should the nurse suspect may have caused the dehiscence?
A) The patient's surgical dressing was changed yesterday and today. B) The patient has vomited three times in the past 12 hours. C) The patient has begun voiding on the commode instead of a bedpan. D) The patient used PCA until this morning.
When changing the position of a patient with a spinal cord injury at T4, the nurse observes the first indication of an episode of autonomic dysreflexia, which is:
a. nausea. b. pallor. c. goose bumps. d. dizziness.
A patient is shouting loudly and is verbally aggressive. What analysis should the nurse make about this behavior?
a. It is acceptable if directed toward staff but not toward another patient. b. It is not harmful and might prevent the patient from physically acting out. c. It is a significant warning sign that the patient may become physically aggressive. d. It allows the patient to vent frustration and alleviate stress without hurting anyone.
A nurse is working on a geriatric unit and caring for a patient on multiple medications. While reviewing the patient's laboratory findings, the nurse notes a slightly abnormal serum creatinine level
The nurse is not concerned, because she understands that serum creatinine is not a good reflection of renal function because a. lean body mass decreases parallel with the decline in renal function. b. lean body mass is increased as renal function declines. c. obese body tissue sequesters creatinine. d. blood urea nitrogen decreases in older adults.