What is the highest-priority safety determination of the psychiatric nursing assessment?
a. past medical history
b. potential for suicide or violence
c. level of mental functioning
d. developmental history
B
The highest priority assessment of safety is to determine the client's potential for suicide or violence. While information regarding past medical history, level of mental functioning, and developmental history may be obtained, they are indicators of an immediate safety issue.
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A nurse plans care for an 83-year-old client who is experiencing age-related sensory perception changes. Which intervention should the nurse include in this client's plan of care?
a. Provide a call button that requires only minimal pressure to activate. b. Write the date on the client's white board to promote orientation. c. Ensure that the path to the bathroom is free from equipment. d. Encourage the client to season food to stimulate nutritional intake.
The nursing instructor is teaching the senior nursing class about pancreatitis. The instructor informs the students that the patient with pancreatitis is at risk for many complications related to the disorder
The instructor points out that a nurse caring for patients with pancreatitis is aware that is it necessary to assess for the onset of complications and take measures to decrease the risk for potential complications. Considering this information, in what position should the patient be placed? A) Supine position B) Lithotomy position C) Trendelenberg position D) Semi-Fowler's position.
Which action is most appropriate when performing ear irrigation to remove excess wax? The nurse should
a. keep the client's head in an upright position. b. occlude the ear canal completely with the syringe. c. spray the external ear with an antiseptic solution. d. use an irrigation solution that is at body temperature.
Ient complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night
A clDuring the nurse's examination, what findings will suggest that the cause of this client's dyspnea is due to heart disease rather than respiratory disease? a. Increased anteroposterior diameter b. Clubbing of the fingers c. Bilateral peripheral edema d. Increased tactile fremitus