The nurse is caring for a patient with bipolar disorder who has been awake for 72 hours and has eaten only small amounts of food. The patient's speech is pressured and unorganized. When planning care for this patient,
what priority nursing diagnosis will the nurse formulate?
1. Alteration of sleeping pattern due to acute mania, as evidenced by decreased sleep.
2. Alteration of sleeping pattern caused by acute mania, manifested by decreased sleep.
3. Risk for injury caused by acute mania, manifested by altered nutrition, decreased sleep, and pressured speech.
4. Risk for injury due to acute mania, as evidenced by altered nutrition, decreased sleep, and pressured speech.
Answer: 4
Explanation: The priority nursing diagnosis for the patient is risk for injury due to acute mania, as evidenced by altered nutrition, dry oral membranes, decreased sleep, and pressured speech. The patient who is experiencing acute mania is at risk for injury due to alterations of nutrition and sleep. While the patient with acute mania is experiencing an alteration of sleeping pattern, this is not the priority nursing diagnosis. All nursing diagnoses are formulated the same way: A problem is identified, and the words "due to" are used, followed by the causative agent. The words "as evidenced by" are then used, followed by the patient's manifestations or presenting symptoms.
You might also like to view...
A nurse is preparing an inservice program about substance abuse and its etiology. Which of the following would the nurse most likely include in the presentation when discussing possible psychologic etiologies?
A) Low self-esteem B) Genetic predisposition C) Dysfunctional family D) Peer influence
The primary reason a client with chronic obstructive pulmonary disease (COPD) often experienc-es fatigue and activity intolerance is related to:
1. The increased presence of surfactant that results in "sticky" alveoli 2. The presence of chronic infections in the lungs and bronchial tree 3. The extra energy that is needed to exhale the air from the damaged lungs 4. The client's elevated anxiety level related to the air hunger being experienced
Identify the most common adverse effects of phenytoin (Dilantin).
A. Skin rashes, hirsutism, and gingival hyperplasia B. Visual disturbances and postural imbalance C. Dizziness and ataxia D. All of the above
Dorsiflexion of the foot is accomplished when a client:
A. Curls the toes down B. Brings the toes together C. Moves the foot so that the toes point up D. Turns the sole of the foot medially