A client diagnosed with brief psychotic disorder tells a nurse about voices telling him to kill the president. Which nursing diagnosis should the nurse prioritize for this client?
A. Disturbed sensory perception
B. Altered thought processes
C. Risk for violence: directed toward others
D. Risk for injury
C
The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices telling him to kill someone is at risk for responding and reacting to the command hallucination. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions.
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An older client with confusion has a prescription to receive a blood transfusion. Which of the following actions should the nurse take to obtain consent?
1. Request the client's family member or next of kin sign the consent. 2. Withhold the blood transfusion until the client's mental status improves. 3. Administer the blood transfusion since a signed consent form is not necessary. 4. Explain the transfusion, help the client sign the consent, and administer the transfusion.
The nurse is planning an educational session for community members to address the issue of school-age child mortality. Which topic should the nurse identify as the highest priority for this population?
A) Cancer B) Assault C) Suicide D) Accidents
Fibrocystic change in breasts is:
1. a disease of the milk ducts and glands in the breasts. 2. a premalignant disorder characterized by lumps found in the breast tissue. 3. lumpiness with pain and tenderness found in varying degrees in breast tissue of healthy women during menstrual cycles. 4. lumpiness accompanied by tenderness after menses.
A patient is experiencing palpitations that are found to be PVCs. Which manifestation should the nurse expect to observe in this patient?
a. Headache b. Confusion c. Lightheadedness d. Tingling of extremities