The husband’s statement about lack of sleep and anxiety over whether the patient is receiving the correct medications are behaviors that support this diagnosis.

Option A: There is no evidence that the patient’s cardiac output is decreased. Alzheimer?s disease and HF often occur together and thus increase the cost of care and health resource utilization; this highlights the need to investigate the relationship between these two conditions. Impaired cognition in HF patients leads to significantly more frequent hospital readmissions and increases mortality rates.
Option C: Ineffective Therapeutic Regimen Management is not a priority as based on the statement.
Option D: Risk for falls is not the priority at this time. Falls are a leading cause of broken hips and other serious injuries in the elderly, and those with Alzheimer’s are at particularly high risk of falling. Problems with vision, perception, and balance increase as Alzheimer’s advances, making the risk of a fall more likely.

The inability to recognize a family member is a new neurologic deficit for this patient, and indicates a possible increase in intracranial pressure (ICP). This change should be communicated to the physician immediately so that treatment can be initiated.

Option B: Increased blood glucose levels is an expected side effect but not an emergency.
Option C: The continued headache also indicates that the ICP may be elevated, but it is not a new problem.
Option D: The weight gain is a common adverse effect of dexamethasone that may require treatment, but is not an emergency.

The patient’s history and assessment data indicate that he may have a chronic subdural hematoma. The priority goal is to obtain a rapid diagnosis and send the patient to surgery to have the hematoma evacuated.

Option A: This can be done after the treatment for any intracranial lesion has been implemented.
Option C: This intervention should be done but is not the priority.
Option D: Administration of phenytoin should be implemented as soon as possible, but the initial nursing activities should be directed toward treatment of any intracranial lesion.

This patient is the most stable of the patients listed. An RN from the medical unit would be familiar with administration of IV antibiotics.

Option A: This patient may need the attention of an experienced neurologic RN.
Option B: A rupture of an aneurysm is fatal and should be assigned to a more experienced RN.
Option D: This patient requires assessment and care from RNs more experienced in caring for patients with neurologic diagnoses.

The priority for interdisciplinary care for the patient experiencing a migraine headache is pain management.

Option B: Anxiety is a correct diagnosis, but it is not the priority. Tension headaches are common for people that struggle with severe anxiety or anxiety disorders. Tension headaches can be described as a heavy head, migraine, head pressure, or feeling like there is a tight band wrapped around their head. These headaches are due to a tightening of the neck and scalp muscles.
Option C: Hopelessness should be addressed as part of the nursing care plan, but it does not require urgency. Hopelessness can result when someone is going through difficult times or unpleasant experiences. A person may feel overwhelmed, trapped, or insecure, or may have a lot of self-doubts due to multiple stresses and losses. He or she might think that challenges are unconquerable or that there are no solutions to the problems and may not be able to mobilize the energy needed to act on his or her own behalf.
Option D: The risk for side effects is accurate, but it is not as urgent as the issue of pain, which is often incapacitating. Focus: Prioritization