A client admitted to the inpatient unit has a diagnosis of schizophrenia, residual type. The nursing diagnosis which has the highest priority for this client is:
1. Disturbed Thought Process
2. Impaired Social Interaction
3. Risk for Violence: Self-Directed or Other-Directed
4. Impaired Verbal Communication
3
Rationale: Risk for Violence: Self-Directed or Other-Directed is most closely related to patient safety, which is the highest priority in nursing care of any client. Impaired Social Interaction, Disturbed Thought Processes, and Verbal Communication are accurate and important nursing diagnoses, but client safety is the highest priority for planning care.
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Which of the following refers to the highest level of human functioning according to Maslow?
a. Biological and physical integrity b. Safety and security c. Self-esteem d. Self-actualization
A 52-year-old female patient is to begin calcitriol therapy. The nurse will advise the patient that an early adverse effect of the drug is often
A) bone pain. B) weight loss. C) polydipsia. D) hypertension.
The nurse is discharging an 11-month-old child who was brought to the emergency room for the treatment of an ear infection and fever
The nurse would include which of the following statements in the discharge teaching to the parents? Standard Text: Select all that apply. 1. "The baby's last bottle before bedtime should only contain water.". 2. "It is important not to prop the baby's bottle during feeding.". 3. "You must rinse the baby's mouth right after the baby falls asleep.". 4. "You must perform oral hygiene more frequently throughout the day.". 5. "The last bottle of the evening should not be given just before the baby goes to sleep.".
A client is being treated for alcohol dependency. During the treatment, the client reports having been treated and undergone detoxification three times in the past
The client states that this time has been more difficult than the previous detoxification experiences. What information can be provided to the client? 1. Aging can impact the ability of the body to handle detoxification from alcohol and drugs. 2. Increased difficulty with alcohol detoxification is likely the result of an addiction to another substance at the same time. 3. The dependency might have been greater this time. 4. With each subsequent episode, detoxification becomes more difficult.