Study your flashcards anywhere!

Download the official Cram app for free >

  • Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/53

Click to flip

53 Cards in this Set

  • Front
  • Back
State the nursing diagnosis for each cause or contributing factor
Blank
Depression, lack of motivation, sensory overload, fatigue, medications
Activity Intolerance
Threat to self-concept, losses
Ansiety
Psychomotor slowing, medications, inactivity, lack of recognition of need to defecate
Constipation
Anxiety, medications, stress
Diarrhea
Hyperactivity, sensory overload, suicidal attempt
Pain
Impaired cerebral function, anxiety, suspiciousness
Impaired Verbal Communication
Stress, altered body function, low self-esteem, dependency, sensory overload, loss of significant other
Ineffective Coping
Patient dependency; history of poor family relationships
Disabled Family Coping
Physical, mental, or social limitations
Deficient Diversional Activity
New or misperceived environment, losses
Fear
Loss of body part, function, role, sigificant other
Anticipatory Greiving
Cognitive impairment, lack of motivation, misperceptions
Ineffective Health Maintenance
Cognitive impairment, misperceptions, lack of motivation
Impaired Home Maintenance
Medications, inactivity, inability to protect self
Risk for Infection
Cognitive impairment, fatigue, medications, suicidal attempt
Risk for Injury
Medications, fatigue
Impaired Physical Mobility
Cognitive impairment, lack of motivation or capacity, suicidal desires
Noncompliance
Depression, anxiety, stress, paranoia, cognitive impairment, suicidal attempt
Impaired Nutrition: Less Than Body Requirements
Depression, anxiety, cognitive impairment, inactivity, suicidal attempt
Impaired Nutrition: More Than Body Requirements
Paranoia, depression, disability, stress
Powerlessness
Cognitive impairment, lack of motivation, knowledge, skill
Self-Care Deficit
Altered body image or function, losses, ageism
Body Image Disturbance
Cognitive impairment, medications, paranoia, sensory deficits, isolation, stress
Sensory-Perceptual Alterations
Depression, anxiety, paranoia, guilt, stress, altered self-concept, medications
Sexual Dysfunction
Cognitive impairment (inability to protect self), malnutrition
Impaired Skin Integrity
Anxiety, paranoia, depression, confusion, medications
Disturbed Sleep Pattern
Altered body part or function, cognitive impairment, anxiety, depression, misperceptions, paranoia, hypochondriasis
Impaired Social Interaction
Anxiety, depression, paranoia, cognitive impairment
Social Isolation
Cognitive impairment, fear, depression, anxiety, stress, isolation
Disturbed Thought Process
Cognitive impairment, anxiety, depression, medications
Impaired Urinary Elimination
Cognitive impairment, paranoia, stress, misperceptions, fear, suicidal attempt
Risk for Other-Directed Violence
Criteria for Diagnosing Alcoholism
Drinks a fifth of whiskey a day or its equivalent in wine or beer (for 180 lb person)
Alcoholic blackouts
Blood alcohol level greater than 150 mg/100mL
Withdrawal syndrome; hallucinations, convulsions, gross tremors, delirium tremens (DTs)
Continued drinking, despite medical advice or problems caused by drinking
State possible causes of behaviors
Blank
Violent/physically abusive (e.g., hitting, kicking, biting, others)
Dementia
Paranoia
Misinterpretation of actions of others
Anger
Feeling powerless
Anxiety
Fatigue
Verbally abusive (e.g., insulting, accusing, threatening)
Dementia
Feeling powerless
Anger
Resisting care
Dementia
Misinterpretation of actions, objects, environment
Depression
Undressing inappropriately
Dementia
Soiled clothing
Irritation from clothing
Feeling to warm
Repetitive actions
Dementia
Agitation
Anxiety
Boredom
Wandering
Dementia
Boredom
Restlessness
Anxiety
Night wandering, restlessness
Dementia
Excess daytime sleeping
Misinterpretation of environment
Sundowner syndrome
Medications (e.g., sedatives, hypnotics, diuretics, laxatives)
Inappropriate sexual behavior
Denentia, leading to poor judgment, loss of inhibition
Misinterpretation of actions and messages from others
Suspiciousness
Paranoid state
Dementia
Suspicious personality
Medications (e.g., anticholinergics, L-dopa, tolbutamide)
State nursing actions for possible behaviors
Blank
Violent/physically abusive (e.g., hitting, kicking, biting, others)
Avoid putting person in situations that trigger behaviors
Recognize warning signs (e.g., cursing, pacing)
Get help to protect self and others
Address in calm, quiet manner
Distract
Move person to area away from others
Verbally abusive (e.g., insulting, accusing, threatening)
Avoid arguing, reasoning, reacting to comments
Distract with activities
Reinforce positive behaviors
Allow maximum decision-making and participation
Resisting care
Prepare for activities
Break activities into single, simple steps
Use alternatives if possible (e.g., sponge bath instead of tub)
Monitor hygiene, nutritional status, I&O, elimination
Undressing inappropriately
Ensure clothing is clean, dry; replace as necessary
Examine clothing for irritation, poor fit
Inspect skin for irritation
Redress
Use clothing that is difficult to unfasten
Offer positive reinforcement when person remains dressed
Repetitive actions
Ignore
Distract with other activities
Replace with a more acceptable repetitive activity (e.g., folding laundry, stacking papers)
Wandering
Schedule times for supervised walking
Provide activities
Safeguard environment (e.g., alarm doors, install door locks that require punching in code to open, ensure window screens cannot be removed)
Ensure person is wearing some form of identification
Familiarize person with environment; orient
Night wandering, restlessness
Provide daytime activities
Provide late day exercise
Toilet before bed time
Keep night light on in bedroom and bathroom
Reassure and orient when person awakens
Safeguard environment
Inappropriate sexual behavior
Relocate person to private area
Distract with other activities
Set limits and remind of acceptable behaviors
Review medications for those that can cause reduced inhibitions (e.g., antianxiety agents) or that increase libido (e.g., L-dopa)
Provide acceptable means of touch, human contact
Suspiciousness
Assess cause
Don’t react to behavior; depersonalize
Protect from harm
Provide explanations; prepare for activities, changes
Afford maximum decision-making
Do not try to explain to person that suspicions are unfounded or wrong; this will not be helpful