A young man has been brought to the emergency department (ED) by police after exhibiting bizarre and violent behavior on the patio outside a restaurant. Upon questioning, the man's girlfriend admits that he had been smoking PCP with his friend
While in the ED, the man continues to exhibit signs of PCP-induced psychosis and has required physical restraints. What nursing outcome should the nurse prioritize in the care of this patient?
A) The client will be physically safe and without injury.
B) The client will demonstrate appropriate social skills.
C) The client will establish a balance of rest, sleep, and activity.
D) The client will verbalize acceptance of responsibility for his behavior.
Ans: A
While the client is actively psychotic and restrained, the need for safety is paramount and would be prioritized over establishing healthy routines, taking responsibility, or demonstrating social skills.
You might also like to view...
The substance most responsible for maintaining the colloid osmotic pressure is
a. intravascular plasma proteins. c. extracellular sodium. b. intracellular potassium. d. interstitial potassium.
Steve, a 7-year-old boy, doesn't come home for dinner on time 3 nights in a row. The parents should:
A) Punish him and make him stay home 3 nights. B) Discuss the problem and give him another three chances. C) Discuss the problem and set outcomes if he is late again. D) Allow him to eat dinner on his own when he shows up.
A neonate is born to a diabetic mother. The baby is very large, weighing 10 lb. The nurse plans care of the neonate accordingly. Nursing care will include:
a. Holding feedings to help reduce blood glucose b. Monitoring blood glucose levels carefully c. Checking vital signs each shift d. None of the above
The nurse commits a medication error. The nurse documents the error in the patient's record and completes the incident report. What does the nurse recognize as the primary reason for doing this?
1. To verify that the patient's safety was protected 2. To protect the patient from further harm 3. To protect the health care facility from litigation 4. To protect the nurse from liability