A nurse is developing a plan of care for a client diagnosed with post-traumatic stress disorder (PTSD) who was admitted to the hospital for suicide ideations and sleep disturbance due to frequent nightmares
Which is the priority nursing diagnosis for this client?
A) Disturbed Sleep Pattern
B) Post-Trauma Syndrome
C) Risk for Other-Directed Violence
D) Risk for Self-Directed Violence
Answer: D
Because the client is experiencing thoughts of suicide, Risk for Self-Directed Violence would be the priority nursing diagnosis. Although the client reports sleep disturbances related to frequent nightmares, Disturbed Sleep Pattern would not be the priority nursing diagnosis. Post-Trauma Syndrome may be appropriate for this client; however, it would not be the priority nursing diagnosis. There is no indication in the findings that the client is at risk for injuring or harming others; therefore Risk for Other-Directed Violence would not be appropriate for this client.
You might also like to view...
A 45-year-old male patient is receiving interferon alfa-2a therapy for hepatitis C. The nurse should teach the patient that he may experience which of the following adverse effects?
A) A metallic taste in his mouth B) Flu-like symptoms C) Numbness and tingling in his extremities D) Reddish-tinged urine
The nurse completes thorough documentation before, during, and after a transfer to ensure _______ of _______
Fill in the blank(s) with correct word
Clients receiving donepezil, rivastigmine, galantamine HBr, or tacrine HCl should be monitored for:
a. hypertensive crisis. c. suicidal tendencies. b. cholinergic crisis. d. tachycardia.
The nurse is communicating with an older client. Which actions demonstrate that the nurse understands the best approaches to communicate with this client?
1. Asking, "What can I do to make you feel safe?" 2. Observed intently listening to the client describe how being alone makes her feel 3. Offering to take the client "out for a walk" 4. Consistently arranging for the client to have her hair done 5. Managing to get a copy of the client's favorite magazine