The nurse cares for an agitated patient who was admitted to the emergency department after taking a hallucinogenic drug and attempting to jump from a third-story window
Which nursing diagnosis should the nurse assign as the highest priority?
a. Risk for injury related to altered perception
b. Ineffective health maintenance related to drug use
c. Powerlessness related to loss of behavioral control
d. Ineffective denial related to lack of control of life situation
ANS: A
Although all the diagnoses may be appropriate for the patient, the highest priority is to address the patient's immediate risk for injury.
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Which form of training would best fit the needs of a night shift worker (11 p.m. to 7 a.m.)?
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