The intervention of highest priority for a client with stage 3 Alzheimer's disease is to:
1. Provide a stimulating environment
2. Maintain hydration and nutrition
3. Set limits on behavioral disinhibition
4. Promote self-care activities
ANS: 2
The severe dementia characteristic of stage 3 renders the client incapable to independently meet hydration and nutrition needs. These needs are basic to life, so they are of highest priority. Op-tion 1 would be nontherapeutic. Options 3 and 4 are inappropriate emphases for care.
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In caring for a patient just admitted with a pelvic fracture, the assessment that would cause the most concern is:
1. a pain level rating of 8 on a 1 to 10 scale. 2. no urinary output for 8 hours. 3. evidence of bruising along the patient's hips and buttocks. 4. complaints of need for back care from resting in bed.
Upon assessment, the nurse notes that a client has dyspnea, crackles in both lung bases, and tires easily upon exertion. Which nursing diagnosis is best supported by these assessment details?
1. Ineffective Breathing Pattern 2. Anxiety 3. Ineffective Airway Clearance 4. Impaired Gas Exchange
Which of the following individuals are communicating a message? Select all that apply
A. A mother spanking her son for playing with matches B. A teenage boy isolating himself and playing loud music C. A biker sporting an eagle tattoo on his biceps D. A teenage girl writing, "No one understands me" E. A father checking for new e-mail on a regular basis
The nurse is caring for a patient who is being treated for extensive burns. The nurse notes the presence of coffee-ground material in the Salem sump catheter. The nurse correctly recognizes which factor as the likely cause?
a. Esophagitis b. Perforated gastric ulcer c. Gastric irritation from the Salem sump tube d. A physiologic stress ulcer