The patient admitted with a diagnosis of Alzheimer's disease is anxious and dehydrated, has reportedly not been eating, and has had a weight loss of 5 lb in 1 week. Which of the following nursing diagnoses is a priority?
a. Fluid volume deficit related to fluid loss
b. Altered nutrition: Less than body requirements related to anorexia
c. Fluid volume excess related to reduced urine output
d. Risk for impaired skin integrity
A
Replacing fluids is the priority. Anorexia is common in the elderly and can be related to many conditions, including dementia. Fluid volume excess is not present. Risk for impaired skin inte-grity is not the priority.
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The nurse is instructing a client prior to a colonoscopy. The client states, "Why do I have to drink this disgusting liquid?" The nurse is most correct to verbalize the goal of the oral preparation as which of the following?
A) "To allow ease of passage of the scope through the colon" B) "To decrease pain associated with fecal matter being pressed against the colon wall" C) "To cleanse the bowel to promote clear visualization of structures" D) "To eliminate gas from the internal portion of the colon"
A patient is admitted with a traumatic brain injury (TBI). The nurse would anticipate participating in interventions toward which immediate goal?
1. Reducing cerebral swelling 2. Confining inflammation to one area 3. Supporting absorption of debris from neuronal death 4. Limiting ischemic tissue injury
Preoperative teaching should include how to perform postoperative leg exercises, which are done to prevent which complication of surgery?
a. ankylosis of the joints c. thrombosis formation b. atrophy of the muscles d. pneumonia
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A) Use a condom during intercourse. B) Avoid intercourse until a Pap test is negative. C) Delay coitus until 10 days after penicillin is started. D) Apply acyclovir topically to lesions prior to intercourse.