A patient, aged 82 years, has Alzheimer's disease. She lives with her daughter's family and goes to a day care facility on weekdays. The nurse at the day care center noticed the patient was unkempt and had multiple bruises
When the daughter arrived to pick her up, the nurse discussed her observations. The daughter became defensive and said that her mother was very difficult to manage. She stated, "My mother is not my mother anymore. She is confused, and she wanders all night. We have to watch her constantly. Last night I fell asleep, and she fell down the stairs. Sometimes I just cannot bear to care for her.". Which nursing diagnosis would be most important to address for this patient? a. Risk for injury related to impaired cognition, judgment, and coordination and lack of caregiver supervision
b. Nonadherence related to confusion and disorientation, as evidenced by lack of cooperation
c. Anxiety related to increasing disorientation, as evidenced by the patient wandering at night
d. Impaired verbal communication related to brain impairment, as evidenced by the patient's confusion
A
The patient is at high risk for injury because of her confusion and the limitations of available supervision. No assessment data support the other diagnoses.
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a. Provide privacy so that the family may touch and kiss the deceased goodbye b. Ask about providing help with the death ceremony c. Carefully wrap the deceased's clothing for the family to take home d. Mention the deceased by name frequently
The nurse is caring for a patient waiting for a heart transplant. The patient's spouse asks the nurse, "Why don't they just choose any heart until the right heart can be found?" What is the nurse's best response?
A) The more closely the new heart matches the patient's tissue, the less aggressive the immune reaction will be. B) When the body responds to specific self-antigens to produce antibodies against its own cells, a severe immune response results. C) Graft-versus-host disease would result making the patient very ill. D) The patient would need to have suppressor T cells infused daily to maintain the heart.
A client has been diagnosed with anorexia nervosa and is currently receiving treatment. During a physical assessment, which finding indicates the client may be noncompliant with therapeutic interventions?
a. Urine specific gravity of 1.002 b. Weight gain of 1 pound since the previous week c. The client opts to wear only a gown when weighed d. The client verbalizes that treatment is making the client feel better
A client has several patches of horny, thickened skin on the palmar surface of the hands and feet. The nurse would document this finding as being:
1. keratosis. 2. linear. 3. serpiginous. 4. dermatomal.