Nokea
An older adult, diagnosed with Alzheimer's disease, lives with family and has multiple bruises. The home health nurse talks with the older adult's daughter, who becomes defensive and says, 'My mother often wanders at night. Last night she fell down the stairs.' Which nursing diagnosis has priority?
- A. Risk for injury, related to cognitive impairment and lack of caregiver supervision
- B. Noncompliance, related to confusion and disorientation as evidenced by lack of cooperation
- C. Impaired verbal communication, related to brain impairment as evidenced by the confusion
- D. Insomnia, related to cognitive impairment as evidenced by wandering at night
Correct Answer: A
Rationale: The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to provide constant supervision. No assessment data support the diagnoses of impaired verbal communication or noncompliance. Sleep pattern disturbance certainly applies to this patient; however, the diagnosis risk for injury is a higher priority.
You may also like to solve these questions
An older adult diagnosed with dementia lives with family and attends an adult day care center. A nurse at the center notices the adult has a disheveled appearance, a strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring?
- A. Psychological
- B. Financial
- C. Physical
- D. Sexual
Correct Answer: C
Rationale: The assessment of physical abuse is supported by the nurse's observation of bruises. Physical abuse includes evidence of improper care, as well as physical endangerment behaviors such as reckless behavior toward a vulnerable person that could lead to serious injury. No data substantiate the other options.
What feelings are most commonly experienced by nurses working with abusive families?
- A. Outrage toward the victim and sympathy for the abuser
- B. Sympathy for the victim and anger toward the abuser
- C. Unconcern for the victim and dislike for the abuser
- D. Vulnerability for self and empathy with the abuser
Correct Answer: B
Rationale: Intense protective feelings, sympathy for the victim, and anger and outrage toward the abuser are common emotions of a nurse working with an abusive family.
An 11-year-old child is absent from school to care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, 'My parents don't like me. They call me stupid and say I never do anything right.' Which type of abuse is likely?
- A. Sexual
- B. Physical
- C. Emotional
- D. Economic
Correct Answer: C
Rationale: Examples of emotional abuse include having an adult demean a child's worth or frequently criticize or belittle a child. No data support physical battering or endangerment, sexual abuse, or economic abuse.
A victim of physical abuse by an intimate partner is treated for a broken wrist. The patient has considered leaving but says, 'You stay together, no matter what happens.' Which outcome should be met before the patient leaves the emergency department? The patient will:
- A. limit contact with the abuser by obtaining a restraining (protective) order.
- B. name two community resources that can be contacted.
- C. demonstrate insight into the abusive relationship.
- D. facilitate counseling for the abuser.
Correct Answer: B
Rationale: The only outcome indicator clearly attainable within this time is for a staff member to provide the victim with information about community resources that can be contacted. The development of insight into the abusive relationship requires time. Securing a restraining (protective) order can be quickly accomplished but not while the patient is in the emergency department. Facilitating the abuser's counseling may require weeks or months.
An older adult diagnosed with dementia lives with family and attends day care. After observing poor hygiene, the nurse at the center talks with the patient's adult child. This caregiver becomes defensive and says, 'It takes all my time and energy to care for my mother. She's awake all night. I never get any sleep.' Which nursing intervention has priority?
- A. Teach the caregiver more about the effects of dementia.
- B. Secure additional resources for the mother's evening and night care.
- C. Support the caregiver to grieve the loss of the mother's ability to function.
- D. Teach the family how to give physical care more effectively and efficiently.
Correct Answer: B
Rationale: The patient's child and family were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their pre-crisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished.