A 63-year-old female has been admitted to the hospital for cholecystitis. She is accompanied by her sister, who provides all the assessment data while the client sits and stares somewhat vacant-ly
You determine that the client is single, lives alone, and lost her job as a secretary last year when she was unable to learn a new computer system. The sister states she has recently had to manage the client's shopping, meal preparation, and finances. Which of the following are appropriate nursing diagnoses?
1. Pain, self-care deficits, situational low self-esteem
2. Anxiety, self-care deficits, disturbed thought processes
3. Impaired home maintenance, disturbed thought process, impaired verbal commu-nication
4. Disturbed body image, anxiety, pain
ANS: 3
The scenario documents client inability to manage ADLs, inability to learn a new computer sys-tem, and reliance on the sister to communicate for her. Data do not support the diagnoses listed in the other options.
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A) It is most effective in preventing medication errors but has less effect on other types of mistakes. B) It provides a means of tracking sentinel events so that they can be studied. C) It can document error reports and identify effective remedies. D) It can provide readily available information to assist nurses in maintaining safety.
What is the most common cause of cerebellar disease?
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It is midmorning on the cardiac unit where you work, and you are getting a new patient. G.P. is a 60-yearold retired businessman who is married and has three grown children
As you take his health history, he tells you that he began feeling changes in his chest about 10 days ago. He has hypertension (HTN) and a 5-year history of angina pectoris. During the past week, he has had frequent episodes of mid-chest discomfort. The chest pain responds to nitroglycerin (NTG), which he has taken sublingually about 8 to 10 times over the past week. During the week, he has also experienced increased fatigue. He states, "I just feel crappy all the time." A cardiac catheterization done several years ago revealed 50% stenosis of the right coronary artery (RCA) and 50% stenosis of the left anterior descending (LAD) coronary artery. He tells you that both his mother and his father had coronary artery disease (CAD). He is currently taking amlodipine (Norvasc), metoprolol (Lopressor), atorvastatin (Lipitor), and aspirin 81 mg/day. What other information are you going to obtain about his episodes of chest pain?