A client diagnosed with paranoid schizophrenia has a history of aggravated assault. A nurse assigns "Risk for other-directed violence" as the client's priority nursing diagnosis
Based on this diagnosis, which would be an appropriate, correctly written outcome for this client? A. The client will not verbalize anger or hit anyone.B. The client will verbalize anger rather than hit others.C. The client will not inflict harm on others during this shift.D. The client will be restrained if verbal or physical abuse is observed during this shift.
C
Preventing injury to others is the appropriate outcome. Outcomes must be client centered, specific, realistic, and measureable and contain a time frame. Answer "A" does not contain a time frame.
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The mother of a young child voices concern about immunizations for her child. The nurse's best response to the mother's concerns is:
a. "Immunization is generally a safe method of avoiding certain diseases and the com-plications that go along with these diseas-es." b. "There are no risk factors associated with immunizations, so there is no reason to worry." c. "I really don't understand the thinking behind people not immunizing their children if it can prevent disease." d. "Recommendations of Healthy People 2020 Goal 14 is to reduce or eliminate cases of vaccine-preventable diseases, so I strongly urge you to immunize your child."
During a discussion between the nurse manager and a staff RN about the RN's recent erratic performance on the unit, the RN states: "After my husband announced that he was leaving me, I thought I was dying
" Identify the best response by the nurse manager. a. "Tell me how you were feeling." b. "That was a pretty unrealistic way to feel. There are a lot of fish in the sea." c. "Your personal life should not affect the way you perform your job." d. "You didn't die, did you? You seem okay now."
While making her rounds, a nurse hears a cry for help. Upon entering the room she finds the
patient on the floor at the end of her bed. The side rails were up, the call button was within reach, and the bed was in its lowest position. The patient stated, "I needed to use the bathroom and I just didn't want to bother the nurses.". How should this incident be written in the occurrence report? A) The patient crawled out of bed attempting to go to the bathroom and fell. The call bell was in reach, the side rails were up, and the bed was in the lowest position. B) The nurse found the patient on the floor at the end of her bed. The side rails were up, the bed was in its lowest position, and the call bell had been within reach. C) Though instructed to call for help, the patient insisted on ambulating without assistance. She was found on the floor. D) The patient was found on the floor. Assisted back to bed. No injuries noted. Instructed to call the nurse prior to getting out of bed in the future.
Which behavior would the nurse anticipate when working with an individual with low literacy?
a. Asking for additional clarification of materials b. Requesting to read the information later c. Having a high level of motivation d. Being overly dependent on others