A client diagnosed with neurocognitive disorder due to Alzheimer's disease is disoriented and ataxic, and he wanders. Which is the priority nursing diagnosis?
A. Disturbed thought processes
B. Self-care deficit
C. Risk for injury
D. Altered health-care maintenance
C
The priority nursing diagnosis for this client is risk for injury. Both ataxia (muscular incoordination) and purposeless wandering place the client at an increased risk for injury.
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The nurse is preparing to receive a newly delivered client. The client is a young single mother who is relinquishing custody of her newborn through an open adoption. What action is most important?
1. Assign the client a room on the GYN surgical floor instead of the postpartum floor. 2. Prepare to have teaching done in time for discharging the client at 24 hours post-delivery. 3. Make an effort to not bring up the topic of the baby, and discuss the mother's health instead. 4. Ask the client if she wants to feed her baby, and how much contact she wants to have.
A patient has completed the acute treatment phase of care following a stroke and the patient will now begin rehabilitation. What should the nurse identify as the major goal of the rehabilitative process?
A) To provide 24-hour, collaborative care for the patient B) To restore the patient's ability to function independently C) To minimize the patient's time spent in acute care settings D) To promote rapport between caregivers and the patient
A patient is admitted to the critical care unit following coronary artery bypass surgery
Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse? a. The assessed values are within normal limits. b. The patient is at risk for developing cardiogenic shock. c. The patient is at risk for developing fluid volume overload. d. The patient is at risk for developing hypovolemic shock.
The four elements that must be present for a person to recover damages as the result of alleged malpractice are duty, breach of duty, actual injury, and:
a. insurance. b. battery. c. intent. d. causation.