The nurse is caring for a patient with bipolar disorder who is agitated and telling everyone he is the king of England. The nurse will select which nursing diagnosis as appropriate for this patient?
1. Self-care deficit
2. Ineffective coping
3. Disturbed sleep pattern
4. Alteration in thought processes
Answer: 4
Explanation: Patients experiencing mania typically exhibit altered thought processes evidenced by agitation and delusions. Self-care deficit, ineffective coping, and disturbed sleep patterns are not evident in this scenario.
You might also like to view...
The nurse is instructing a bioterrorism class regarding anthrax. How can anthrax be transmitted?
a. From person to person b. Through microscopic skin punctures c. Through inhalation of the spores d. By exposure to animals that have anthrax
Which type of stool would the nurse assess in a client with an illness that causes the stool to pass through the large intestine quickly?
A) Hard, formed B) Black, tarry C) Soft, watery D) Dry, odorous
The nurse wants to assess visual acuity with a preschool child who is developmentally delayed. The nurse selects the Blackbird Preschool Vision test, which is best described as a test that:
a. presents the letter B in various positions b. is named after a person by the name of Blackbird c. uses blackbirds of various sizes flying in different directions d. offers various birds of various colors doing various things
A patient is complaining of increased pain to the area of a third-degree burn covering the entire arm. The nurse suspects compartment syndrome. For which intervention would the nurse prepare the patient?
1. Transportation to the whirlpool 2. Application of multiple ace wraps over the current gauze dressing 3. An escharotomy performed by the physician 4. Skin grafting performed by the physician