The priority nursing diagnosis of a 45-year-old client with auditory hallucinations would be which of the following?
1. Risk for Violence, Self-Directed or Other-Directed
2. Disturbed Thought Processes
3. Individual Ineffective Coping
4. Impaired Verbal Communication
1. Risk for Violence, Self-Directed or Other-Directed
Rationale:
Maintaining a safe environment is the priority diagnosis. Although the client has impaired thought processes, this is not the priority diagnosis at this time. Individual ineffective coping and impaired verbal communication are also correct diagnoses, but the key word here is "priority," and this client has a potential or risk for harm to self or others.
You might also like to view...
A conflict between two groups has gone through the conflict management process, but the groups are still not working well together. Is this a normal situation?
1. Yes; groups often have difficulty letting go of the conflict. 2. Yes; when bargaining is used, the outcome is often unpredictable. 3. No; these groups should go back through the problem-solving process. 4. No; some problems are not amenable to conflict management.
Ms. Jones is a 31-year-old female patient who presents for a routine physical examination. Which examination technique will be used first?
a. Light palpation b. Deep palpation c. Percussion d. Inspection
A 30-year-old multiparous woman has a boy who is 2½ years old, and now an infant girl. She tells the nurse, "I don't know how I'll ever manage both children when I get home."
Which suggestion would best help this woman decrease sibling rivalry? 1. Tell the older child that he is a big boy now and should love his new sister. 2. Let the older child stay with his grandparents for the first 6 weeks to allow him to adjust to the newborn. 3. Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him. 4. Realize that the regression in habits and behaviors in the older child is a typical reaction and that he needs extra love and attention at this time.
The term "follower" has replaced which of the following terms?
a. superior b. leader c. Subordinate d. participant