A client with stage 1 Alzheimer's disease is described by her husband as having lost energy and
preferring to remain at home rather than attend club meetings and church.
The husband has been
doing the grocery shopping because his wife cannot remember what to purchase and is unable to
find her way around the store unassisted. Which nursing diagnosis commonly used for clients with
Alzheimer's disease can be established for the client at this time?
a. Risk for injury
b. Impaired memory
c. Self-care deficit
d. Caregiver role strain
B
Memory impairment is present. Data are not present to suggest the other diagnoses.
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A patient who is severely brain damaged has decerebrate posturing with extended extremities. The nurse understands that damage most likely occurred in which area of the brain?
a. Cerebellum b. Cerebrum c. Brain stem d. Hypothalamus
After injuring his knee during a basketball game, Michael Evans, age 16, is brought to the emergency department. Assessment reveals a positive McMurray's test. What does this finding suggest?
A) Torn cartilage B) Effusion in the joint C) Bruised patella D) Joint instability
Which assessment findings for a one-hour-old infant should the nurse report?
A) Temperature of 97.6°F B) Heart rate 158 C) Respiratory rate 42 D) Blood sugar 42 mg/dL
The nurse assigns a nursing diagnosis of ineffective breathing pattern. Which of the following sleep conditions would support this diagnosis?
a. Insomnia b. Narcolepsy c. Obstructive sleep apnea d. Sleep deprivation