A nurse who is responsible for planning many of the aspects of care on a subacute geriatric unit is aware of the high incidence and prevalence of vestibular disorders among older adults
In individuals with these disorders, the nurse should identify what consequent nursing diagnosis?
A) Risk for impaired tissue integrity related to vestibular disorder
B) Risk for chronic confusion related to vestibular disorder
C) Risk for aspiration related to vestibular disorder
D) Risk for falls related to vestibular disorder
D
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A critical care nurse is caring for a client in a hypertensive crisis. Blood pressure is being reduced slowly. If the blood pressure is lowered too much too quickly, what is the patient is at risk for?
A) A myocardial infarction B) A cerebral infarction C) Renal failure D) All of the above
A patient is admitted into a mental health unit screaming and kicking. Although this patient is acting out, she also is verbalizing that her leg is hurting. What type of planning would benefit this patient the most?
A. Short-term goal B. Long-term goal C. Intervention D. Evaluation
A nurse on the night shift notices that a client is grinding his teeth while sleeping. What health problem should the nurse document for this client?
A) Bruxism B) Insomnia C) Narcolepsy D) Cataplexy
You are examining a woman in the clinic. Which of the following are probable signs that the woman is pregnant? Select all that apply
a. Amenorrhea b. Fatigue c. Uterine changes d. HCG in blood or urine e. Braxton Hicks contractions f. Breast tenderness and enlargement