During a home health visit, the nurse assesses an older adult client who reports decreased appetite and recent weight loss. The nurse is considering the nursing diagnosis Imbalanced Nutrition: Less Than Body Requirements. Which assessment finding would NOT support this nursing diagnosis?

An older adult client reports chronic low fluid intake and recent difficulty with bowel movements. The nurse understands that inadequate fluid intake slows intestinal transit time, allowing increased absorption of water from intestinal contents. How will this change most likely affect the client’s stool?

An older adult client whose spouse died 6 months ago tells the nurse stories about the deceased spouse. When care has been completed, the client thanks the nurse for listening and states, “My children will not listen to these stories.” From which type of intervention would this client most likely benefit?

The nurse is providing care to a client who has just received a diagnosis of cancer. Which findings would suggest that the client is experiencing spiritual distress? Select all that apply.

The home health nurse is visiting an older client with a terminal illness for a routine medication check. The nurse determines that the client has declined since the last home visit. The nurse suggests that the client should be transported to the hospital; however, the family members state that they want the client to stay in the home. Which action by the nurse is most appropriate?

The nurse is caring for an older adult client admitted for treatment of pneumonia. During the previous assessment 10 minutes ago, the client was alert and oriented to person, place, time, and situation. Upon entering the room, the nurse notes the client is now confused, disoriented, and attempting to climb out of bed. Which nursing action should the nurse take FIRST?

The nurse is providing teaching to the spouse of a client who was recently diagnosed with Alzheimer disease. The spouse states, “I don’t understand how this happened. No one else in the family has ever had Alzheimer disease.” Which response by the nurse is most appropriate?

A nurse is caring for a client who has died following an intentional medication overdose. The client’s partner remains at the bedside but appears quiet, serious, and does not display visible signs of crying or emotional distress. Which explanation should the nurse consider as the most likely reason for the partner’s reaction?  

A client presents to the clinic and states, “When I move my head, I feel like the room is spinning around me.” The nurse recognizes this symptom as vertigo. Which description best explains vertigo?

 A patient whose parent recently died states, “I keep thinking I should have done more for them before they died.” Which response by the nurse is most therapeutic?