A client with a dissociative disorder has the nursing diagnosis ...

[panfilo]

A client with a dissociative disorder has the nursing diagnosis of disturbed body image. Which nursing interventions would address the nursing priority of determining the coping abilities and skills of this client? (Select all that apply.)
 
  a. Assess the client's current level of adaptation.
  b. Help the client differentiate between isolation and loneliness.
  c. Note the use of addictive substances.
  d. Identify previously used coping strategies and their effectiveness.

Question 2

A 78-year-old resident of a skilled nursing facility has hypertension and cardiac disease. This resident is usually alert and oriented but this morning tells the nurse, My family visited during the night. They brought flowers and candy to me..
 
  In reality, the patient's family lives 200 miles away. The nurse should first suspect that the resident: a. may be developing Alzheimer's disease associated with advanced age.
  b. may have a cognitive impairment associated with medication actions.
  c. had a stroke and developed sensory perceptual alteration.
  d. has an alcohol-related cognitive impairment.

[Athena23]

Answer to Question 1

A, C, D
The client's current level of adaptation must be assessed as a baseline for the plan of care. Noting the use of addictive substances may reflect dysfunctional coping mechanisms. Identifying whether previously used coping strategies were effective will reveal whether any of them can be used again. Helping the client differentiate between isolation and loneliness is an intervention that is directed toward the nursing diagnosis of social isolation.

Answer to Question 2

B
A resident taking medications is at high risk for becoming confused due to medication side effects, drug interactions, and delayed excretion. The nurse should report the event and continue to assess for cognitive impairment. Symptoms of dementia tend to develop slowly but persist over time. The history would alert the nurse to alcohol-related cognitive impairment.

[panfilo]

TYSM

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Gracias!