A depressed patient repeatedly tells staff that he's evil and that his "insides are rotting" because God is punishing him. What would the priority nursing diagnosis for this patient be?
a. Spiritual distress
b. Disturbed thought process
c. Situational low self-esteem
d. Ineffective health maintenance
B
The patient is demonstrating delusional thinking suggestive of worthlessness and guilt. The delusional thinking indicates significant cognitive disorganization, potentially placing the patient at risk due to impaired judgment. The cognitive disorganization also interferes with patient learning and understanding and would make it more difficult for the patient to respond to interpersonal therapies. If the issue of impaired thought process is not addressed, the patient will have more difficulty responding to other forms of treatment and may experience harm. Therefore, disturbed thought process is the priority concern in this situation. The other diagnoses do not involve issues of risk and thus are lower priorities.
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Which of the following instructions will the nurse provide to a patient with inflammatory bowel disease regarding nutritional management of this condition?
A) Consume a bland, high-residue, high-protein, and high-vitamin diet. B) Consume a bland, low-residue, low-protein and low-vitamin diet. C) Consume a bland, low-residue, high-protein, and high-vitamin diet. D) Consume a bland, high-residue, low-protein, and low-vitamin diet.
A client is prescribed an antihypertensive drug. Which of the following would the nurse include in the teaching plan to promote the best outcome for the client? Select all that apply
A) "Never discontinue use of the antihypertensive drug except on the advice of the physician." B) "Avoid the use of nonprescription drugs unless approved by the physician." C) "Avoid alcohol unless its use has been approved by the physician" D) "Know that unexplained weakness or fatigue is a normal adverse reaction." E) "Notify the physician if the diastolic pressure suddenly increases to 130 mm Hg or higher."
You are caring for an elderly patient with Alzheimer's disease. The patient has just returned to the unit to begin supplemental tube feedings through a gastrostomy tube. What should you be most concerned with the potential for?
A) Hypoglycemia B) Fluid volume excess C) Aspiration D) Constipation
Which of the following statements about links between families and their community is inaccurate?
1. The negative influences of poverty and unrest continue for generations even after community conditions improve. 2. Understanding the culture of the community is essential for being able to address family health needs. 3. Families in low-resourced areas contend with malnutrition. 4. Political unrest has little effect on the health and well-being of families.