Which of these options is a patient outcome indicating positive progress toward resolving the nursing diagnosis of Acute confusion?
a. Side rails are up with bed alarm activated.
b. Patient denies pain while ambulating with assistance.
c. Patient wanders halls at night.
d. Patient correctly states names of family members in the room.
ANS: D
The identified nursing diagnosis is Acute confusion. The outcome for this diagnosis would address a decrease or absence of confusion. One sign of orientation is when a patient responds to questions appropriately. Thus, one possible sign that a patient's confusion is improving is seen when a patient can correctly state the names of family members in the room. Keeping the side rails up and using a bed alarm are interventions to promote patient safety and prevent falls. The patient's denying pain indicates positive progress toward resolving a diagnosis of Acute or Chronic pain. The patient's wandering the halls is a sign of confusion.
You might also like to view...
From his educational experience prior to entering his nursing program, a nursing student is aware that he suffers from text anxiety that is often intense
As well, the student believes that he has been unsuccessful on some previous exams directly because of his test anxiety. What action should the student take to address this problem? A) Take an NCLEX-PN® review course B) Become a member of a study group with some classmates C) Ask his nursing instructors for remedial help D) Explore the possibility of professional counseling
The nurse is performing a physical examination of an 8-year-old girl who was bitten by her kitten. Which of the following assessments would be most indicative of cat scratch disease?
A) Swollen lymph nodes B) Strawberry tongue C) Infected tonsils D) Swollen neck
Clients receiving care in the home may have progressive, chronic diseases
Indicate whether the statement is true or false
The nurse has reinforced preoperative teaching with a patient about coughing and deep breathing techniques. Which of the following statements by the client would indicate a correct understanding of the teaching? (Select all that apply.)
a. "I should cough and deep breathe 10 times every hour while awake." b. "I should avoid deep breathing after surgery." c. "I should take shallow breaths after surgery to prevent pain." d. "I should cough and deep breathe beginning 2 days after my surgery." e. "Coughing and deep breathing helps prevent respiratory problems."