The daughter of an older patient with dementia tearfully tells the nurse that she doesn't know what's wrong with her mother, who has begun accusing the family of holding her prisoner. Which nursing diagnosis would be appropriate for this patient?
a. Powerlessness
b. Defensive coping
c. Ineffective coping
d. Disturbed thought processes
ANS: D
Paranoid thinking is common in patients with dementia. Inability to correctly interpret envi-ronmental clues and to think logically leads to delusional thinking as the patient tries to make sense of a confusing world. The remaining options are not supported by the data in the sce-nario.
You might also like to view...
The nurse is caring for a client on a mechanical ventilator whose vital signs are T; 97.4°F oral; P: 112; R: 32; BP: 88/54
The client has no spontaneous respirations, pupils are dilated and not responsive to light, EEG is flat, and the client has no reflexes. The client cannot be aroused, and has no response to stimulation. There has been no change in the client's condition for the past three days, and he is not receiving a controlled substance. The nurse recognizes that this client is: 1. Comatose. 2. In a vegetative state. 3. Brain-dead. 4. Obtunded.
A patient has developed severe contact dermatitis with burning, itching, cracking, and peeling of the skin on her hands. What should the patient be instructed to do?
A) Wear powdered latex gloves B) Wash hands with antibacterial soap C) Maintain room temperature at 80 F D) Keep hands will moisturized
A 10-year-old boy has been admitted to the hospital with respiratory acidosis. The nurse suspects that which of the following conditions most likely caused the child to develop this condition?
1. Noncompliance with type 2 diabetic medications 2. Severe diarrhea for several days 3. Obesity 4. Hyperthyroidism
The nursing student knows that ethics is a part of which branch?
a. Sociology b. Law c. Philosophy d. Medicine