Before a client became depressed, she was an active, involved mother with her three children, often attending their school functions and serving as a volunteer
She is hospitalized for major depressive episode and now reveals that she feels like an unnecessary burden on her family. Which of the following nursing diagnoses is most appropriate?
A) Anxiety related to side effects of medication
B) Disturbance of self-concept related to feelings of worthlessness
C) Anger related to marital disagreements
D) Apathy related to fatigue and sleeplessness
Ans: B
The client does not express anxiety, anger, or apathy. Instead, she has experienced a change from being an involved, interested mother to feeling as though she is a burden, which would be reflective of a disturbance of her self-concept. The self-concept changes she is experiencing are related to feelings of worthlessness brought on by the depressive episode.
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An 84-year-old patient who has returned from the PACU is oriented to name only and has been diagnosed with delirium. The nurse should explain the following to the patient's family:
A) There is nothing to worry about. B) Delirium involves a progressive decline in memory loss. C) Delirium may only last a short time. D) Delirium is generally more prevalent in women.
An older resident in a senior community tells a nurse: "I am really worried. I joined an exercise class, and I just learned everyone's name yesterday, and I cannot remember them all today. Am I developing Alzheimer's disease?"
The best response by the nurse is: a. "You should be concerned. It is very un-usual to forget something that you just learned." b. "There is no reason to be concerned. Short-term memory decreases with age." c. "Don't worry, a decline in both short- and long-term memory is a normal part of get-ting older." d. "Although it is normal to have some changes in memory, forgetting names is very unusual."
When the nurse measures waist-to-hip ratio and calculates the midarm muscle circumference (MAMC), the nurse is assessing
a. overall muscle strength and density compared to fat stores. b. proportion and distribution of muscle mass and body fat. c. reserves of protein and calories stores in the muscle. d. the size of the body frame related to body weight.
Color blindness is more common in women than in men.
Answer the following statement true (T) or false (F)