Nokea
An older adult with Lewy body dementia lives with family. After observing multiple bruises, the home health nurse talked with the daughter, who became defensive and said, My mother often wanders at night. Last night she fell down the stairs. Which nursing diagnosis has priority?
- A. Risk for injury related to poor judgment, cognitive impairments, and inadequate supervision
- B. Wandering related to confusion and disorientation as evidenced by sleepwalking and falls
- C. Chronic confusion related to degenerative changes in brain tissue as evidenced by nighttime wandering
- D. Insomnia related to sleep disruptions associated with 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 give constant supervision. Insomnia, chronic confusion, and wandering apply to this patient; however, the risk for injury is a higher priority.
You may also like to solve these questions
Which of the following are risk factors for pathological gambling?
- A. Impulsivity.
- B. Alcohol abuse.
- C. Parents who gamble.
- D. All of the above
Correct Answer: D
Rationale: All listed factors"impulsivity, alcohol abuse, parental gambling, and tolerance"are recognized risk factors for developing pathological gambling.
Which of the following barriers to health care may have created health disparities for lesbians in the U.S.?
- A. Homophobia
- B. Lack of insurance
- C. Socioeconomic level
- D. Level of education
Correct Answer: A
Rationale: Homophobia drives disparities by limiting access and comfort in care settings.
Place the following phases of crisis in the correct sequential order. Order each response with a number from first to last, with #1 as the first phase of crisis to #4 which is the fourth phase of crisis. 1. The signs and symptoms of the General Adaptation Syndrome 2. Detachment and disorientation 3. Trying alternative methods of coping 4. The use of psychological ego defense mechanisms
- A. 3,2,1,4
- B. 1,2,3,4
- C. 4,3,2,1
- D. 4,3,1,2
Correct Answer: B
Rationale: Crisis phases (B: 1,2,3,4) follow GAS, detachment, coping attempts, and defense mechanisms.
Which of the following services would be especially helpful for terminally ill Muslim patients?
- A. Referring the patient for additional tests
- B. Negotiating a plan for outside visitors, especially the Imam
- C. Providing patients with motivational pamphlets
- D. Serving regular hospital meals
Correct Answer: B
Rationale: Facilitating Imam visits supports spiritual needs, crucial for Muslim patients at end-of-life.
The most appropriate nursing intervention with Jenny (from question 5) would be to:
- A. Make arrangements for her to start attending Alateen meetings.
- B. Help her identify the positive things in her life and recognize that her situation could be a lot worse than it is.
- C. Teach her about the effects of alcohol on the body and that it can be hereditary.
- D. Refer her to a psychiatrist for private therapy to learn to deal with her home situation.
Correct Answer: A
Rationale: The correct answer is A because Alateen meetings provide support and understanding for teenagers living with family members struggling with alcoholism. Attending these meetings can help Jenny feel less alone, gain coping strategies, and build a support network with peers in similar situations.
Choice B is incorrect as it minimizes Jenny's struggles and may invalidate her feelings. Choice C focuses on the biological aspect of alcoholism, which may not address Jenny's emotional needs. Choice D involves a referral to a psychiatrist for private therapy, which may not provide the peer support and understanding that Alateen meetings can offer.