The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis addresses the complication of the sensory deficit that places the patient at greatest risk for injury?
a. Risk for falls
b. Body image disturbance
c. Social isolation
d. Fear
A
A visual disturbance poses great risk for injury due to falling from impaired depth perception and inability to see obstacles. Body image disturbance, social isolation, and fear are all valid nursing diagnoses that apply to a patient with vision deficit; however, they do not address the greatest risk for injury.
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The older male adult was oriented and responded correctly in the hospital, but he is dis-oriented and confused in his home after discharge
Which is the first issue the home nurse should examine to determine if an environmental issue is contributing to the patient's condition at home? a. Complaints of shivering b. Temperature of household c. Types of food preparation d. Patient indicators of injury
Which of these processes protects the body against future invasions of already experienced antigens?
a. acquired immunity c. immune response b. humoral immunity d. systemic immunity
A patient with mania dances around the unit, seldom sits or sleeps, and monopolizes conversations. Which nursing intervention will best assist the patient with energy conservation?
a. Monitor physiological functioning. b. Provide a subdued environment. c. Observe for mood changes. d. Supervise personal hygiene.
A patient states, "I'm really turned off when the doctor hurries out of here." The nurse responds, "You're feeling upset with your doctor because he doesn't spend enough time with you." This interaction demonstrates
a. summarizing. b. validating. c. clarifying. d. reflecting.