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 vacantly. 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?

Correct Answer: C

Rationale: The correct answer is C: Impaired home maintenance, disturbed thought process, impaired verbal communication. Rationale: 1. Impaired home maintenance: The client is unable to take care of herself and her living environment due to the need for assistance in shopping, meal preparation, and finances. 2. Disturbed thought process: The client's vacant stare and inability to learn new tasks suggest cognitive impairment or confusion. 3. Impaired verbal communication: The client's lack of verbal interaction and reliance on her sister for assessment data indicate difficulties in expressing herself. Summary: A: Pain, self-care deficits, situational low self-esteem - Pain is not mentioned in the scenario, and the client's issues go beyond self-care deficits and low self-esteem. B: Anxiety, self-care deficits, disturbed thought processes - While anxiety and disturbed thought processes may be present, impaired home maintenance and impaired verbal communication are more appropriate diagnoses based on the scenario. D: Disturbed body image, anxiety, pain - Disturbed

Correct Answer: B

Rationale: Correct Answer: B - Depression from the loss of his wife Rationale: Given the client's recent loss of his wife and subsequent changes in behavior, the most likely cause of his confusion is depression. Depression can manifest as cognitive impairment in older adults, leading to symptoms such as confusion and memory problems. Additionally, grief and loss can exacerbate depressive symptoms in elderly individuals, further contributing to cognitive difficulties. Summary of other choices: A: Dementia - Dementia typically presents with gradual cognitive decline over time, not a sudden onset following a specific event like the loss of a loved one. C: Hypoxia of the brain - Hypoxia would likely present with more acute symptoms and physical signs, such as shortness of breath or cyanosis. D: Delirium from medications - Delirium is characterized by acute onset and fluctuating course, often related to medication changes or other medical conditions, rather than an emotional trigger like grief.

Correct Answer: D

Rationale: The correct answer is D: Place large signs on doors or entryways that identify the room. This is the best response because it directly addresses the issue of the client's confusion and disorientation by providing clear visual cues to help her navigate the home environment effectively. By labeling the rooms with large signs, the client can easily recognize where she is and find what she needs. This strategy helps reduce her anxiety and frustration, promoting a sense of independence and safety. Choices A, B, and C are incorrect because they do not specifically target the client's cognitive challenges related to Alzheimer's disease. Keeping rooms well lit, having a simple environment, and using clocks with large letters are helpful suggestions but do not address the primary issue of the client's spatial disorientation and confusion. Placing large signs on doors directly addresses the client's specific needs and is the most effective strategy in this situation.

Correct Answer: C

Rationale: The correct answer is C because observing the patient's response to meals, including food refusal or purging behavior, is crucial in assessing the patient's eating habits and behaviors associated with anorexia nervosa. This assessment helps in understanding the patient's relationship with food and identifying any disordered eating patterns. Monitoring fluid intake exclusively (Choice A) is not sufficient as it overlooks the broader aspects of the patient's eating behaviors. Checking weight daily without discussing it with the patient (Choice B) can be triggering and may not provide a comprehensive understanding of the patient's eating disorder. Monitoring for signs of vitamin and mineral deficiencies (Choice D) is important but does not directly address the specific behaviors associated with anorexia nervosa.

Correct Answer: A

Rationale: The correct answer is A: The acute phase reaction. This behavior is common in the immediate aftermath of a traumatic event like sexual assault. The victim may exhibit physical and emotional symptoms such as rocking back and forth, confusion, disorientation, and numbness. This reaction is a natural response to the overwhelming stress and trauma experienced. Choice B, the angry stage of rape, is incorrect as it does not capture the immediate post-assault response. Choice C, trauma syndrome, is too vague and does not specifically address the behavior described. Choice D, None of the above, is incorrect as the victim's behavior aligns with the acute phase reaction typically seen in trauma survivors.