A 78-year-old resident of a skilled nursing facility has hypertension and cardiac disease. This resident is usually alert and oriented but this morning tells the nurse, "My family visited during the night. They brought flowers and candy to me."
In reality, the patient's family lives 200 miles away. The nurse should first suspect that the resident: a. may be developing Alzheimer's disease associated with advanced age.
b. may have a cognitive impairment associated with medication actions.
c. had a stroke and developed sensory perceptual alteration.
d. has an alcohol-related cognitive impairment.
B
A resident taking medications is at high risk for becoming confused due to medication side effects, drug interactions, and delayed excretion. The nurse should report the event and continue to assess for cognitive impairment. Symptoms of dementia tend to develop slowly but persist over time. The history would alert the nurse to alcohol-related cognitive impairment.
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A client tells the nurse that he firmly believes he is ill because the building where he works is dirty with poor ventilation. The nurse realizes this client is demonstrating a mind-set that is strongly influencing his decisions and behaviors or a(n):
a. paradigm. b. defense mechanism. c. imagery. d. stressor.
A client is taking garlic and hawthorn supplements. The nurse would ask further questions to elicit information on a possible history of
a. atherosclerosis. b. hypertension. c. smoking. d. varicose veins.
A patient is admitted with possible botulism poisoning after eating home-canned green beans. Which intervention ordered by health care provider will the nurse question?
a. Encourage oral fluids to 3 L/day b. Document neurologic symptoms c. Position patient lying on the side d. Observe respiratory status closely
The nurse draws a picture of fetal circulation showing how blood flows from the right atrium to the left atrium through the:
a. Ductus arteriosus b. Foramen ovale c. Ductus venous d. Pulmonary arteries