The nurse is assessing a patient who is believed to be at risk for attempting suicide. Which assessment question directly asks about suicidal intent or ideation?
a. “How is your life?”
b. “What struggles in your life are upsetting you?”
c. “How are you trying to solve some of these problems?”
d. “Do you have anything in your home or available to you that you could use to harm yourself?”
d. “Do you have anything in your home or available to you that you could use to harm yourself?”
While all of these questions are appropriate to ask a patient who may be at risk for suicide, the only question that asks about suicidal intention or ideation is whether the patient has anything in the home that could be used to harm him- or herself. The other questions are aimed at establishing empathy with the patient.
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A patient who has been pacing rapidly for the past hour cannot immediately be located on the unit. When he is found, he is in his closet, rocking back and forth rapidly and talking rapidly to himself
When staff approach, he only seems to notice them momentarily, then leaves his room and begins running up and down the hallway. Which of the following interventions should be attempted at this point? a. "I want you to breathe deeply as I do, in slowly, now hold it, now breathe out.". b. "I have some medicine that will calm you; would you like it by pill or in a shot?" c. In a calm but direct voice say: "Stop running. I will stay with you. Walk with me.". d. Gather a show of force and say: "You need to come with us now to seclusion.".
A nurse is teaching a group of nursing students about drug abuse. Which statement by a student indicates a need for further teaching?
a. "Patients who experience physical depen-dence will show compulsive drug-seeking behavior." b. "People who are addicted to a drug do not necessarily have tolerance to that drug." c. "Physical dependence means that absti-nence syndrome will occur if a drug is withdrawn." d. "Physical dependence often contributes to addictive behavior but does not cause it."
A woman of Korean descent has just given birth to a son. Her partner wishes to give her sips of hot broth from a thermos they brought with them. They have refused your offer of ice chips or other cold drinks for the client. The nurse should:
1. Explain to the client that she can have the broth if she will also drink cold water or juice. 2. Encourage the partner to feed the client sips of their broth. Ask if the client would like you to bring her some warm water to drink as well. 3. Explain to the couple that food can't be brought from home, but that the nurse will make hot broth for them. 4. Encourage the client to have the broth, after the nurse takes it to the kitchen and boils it first.
A hospitalized elderly client suddenly does not recognize his daughter and complains that his wife has not visited him, even though she has been dead for 5 years. The client was clear of mind and thought prior to hospitalization
What NANDA nursing diagnosis problem statement would the nurse use for this client? 1. Acute Confusion 2. Anxiety 3. Risk for Autonomic dysreflexia 4. Ineffective Coping