When reviewing the history of a newly admitted patient diagnosed with severe chronic depression, the nurse is most concerned about patient safety issues when noting:
a. The patient's Axis II includes a diagnosis of mental retardation
b. Documentation that the patient has been noncompliant regarding medications
c. The patient's current Global Assessment of Functioning (GAF) Scale rating is 9
d. Reference to a recent physical injury resulting from the patient's impulsive be-havior
ANS: C
The Global Assessment of Functioning (GAF) Scale is one of the tools use to assess patient functioning and possible prognosis. It is coded on a numerical continuum, with 1 indicating little danger and 10 indicating severe or persistent danger, and possible suicidal potential. Mental deficiency may contribute to issues of safety but it is not a significant risk factor. Noncompliance may contribute to the patient's depression but it is not the greatest concern identified. Although past history is considered a predictor of future behavior, this is more related to the safety of others than to the patient.
You might also like to view...
What helmintic infestation occurs in tropical areas and is carried by snails?
A) Schistosomiasis B) Platyhelminths C) Trichinosis D) Filariasis
An older patient with multiple rib fractures is diagnosed with osteomalacia. What should the nurse teach the patient to help prevent further problems from this diagnosis? Standard Text: Select all that apply
1. Begin steps to stop smoking. 2. Increase the intake of chicken and fish. 3. Ingest dairy products fortified with vitamin D. 4. Engage in weight bearing exercises 3 times a week. 5. Expose the hands and the face for 15 minutes a day to direct sunlight.
A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of impaired breathing pattern related to anxiety. Which nursing action is most appropriate to include in the plan of care?
a. Titrate oxygen to keep saturation at least 90%. b. Discuss a high-protein, high-calorie diet with the patient. c. Suggest the use of over-the-counter sedative medications. d. Teach the patient how to effectively use pursed lip breathing.
A nursing instructor is preparing for a class discussion on polypharmacy and older adults. Which of the following would the instructor expect to include?
A) The risk for drug abuse, although present, is fairly rare in this population. B) Older adults often experience a greater risk for adverse reactions. C) Medications are usually prescribed in higher doses initially and then gradually reduced. D) Age-related pharmacokinetic changes enhance the drug's therapeutic effectiveness.