A patient diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof, suspicious, and says, "Two staff members I saw talking were plotting to kill me."
Based on data gathered at this point, which nursing diagnoses relate? Select all that apply.
a. Risk for other-directed violence
b. Disturbed thought processes
c. Risk for loneliness
d. Spiritual distress
e. Social isolation
ANS: A, B
Delusions of persecution and ideas of reference support the nursing diagnosis of disturbed thought processes. Risk for other-directed violence is substantiated by the patient's feeling endangered by persecutors. Fearful individuals may strike out at perceived persecutors or attempt self-harm to get away from persecutors. Data are not present to support the other diagnoses.
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a. Impaired Memory c. Diarrhea b. Ineffective Denial d. Social Isolation
A 50-year-old man vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. To determine possible risk factors for gastritis, the nurse will ask the patient about
a. the amount of saturated fat in the diet. b. any family history of gastric or colon cancer. c. a history of a large recent weight gain or loss. d. use of nonsteroidal antiinflammatory drugs (NSAIDs).
What would a circulating nurse working in the operating room consider a priority for a patient undergoing an artificial valve replacement regarding providing documentation of artificial de-vices to the manufacturer?
a. Counting sponges and sutures b. Completing forms for the artificial valve manufacturer c. Covering for the surgical technician breaks d. Assessment of lung sounds
How should a patient be positioned for a cleansing or oil-retention enema?
A. In the supine position B. In the prone position C. Lying on the right side D. In the left-lying Sims' position