The nurse is caring for an adolescent with bipolar disorder who has expressed the desire to harm self. What is the priority nursing diagnosis for this client?
A) Powerlessness related to mood instability
B) Impaired Social Interaction
C) Risk for Suicide
D) Social Isolation related to disorder
Answer: C
The priority for an adolescent with bipolar disorder and suicidal ideas is safety. Risk for Suicide is the nursing diagnosis that would address safety for the client. The other diagnoses have a lower priority and can be addressed once safety has been ensured.
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A nurse is planning an educational event for a local group of citizens who live with a variety of physical and cognitive disabilities. What variable should the nurse prioritize when planning this event?
A) Health-promotion needs of the group B) Relationships between participants and caregivers C) Wellness state of each individual D) Learning needs of caregivers
The nurse is caring for a 79-year-old male who has a non–weight-bearing cast on the left lower extremity. The patient ambulates without using a walker despite repeated instruction from the nurse to call for assistance
Which response by the nurse is most likely to keep the patient from falling? a. Apply a vest restraint and offer frequent toileting. b. Plan fall prevention with patient, family, and healthcare provider. c. Inform family that the patient needs phys-ical restraints. d. Document that the patient has a high po-tential for falling.
Your client needs a bone marrow aspiration. Which site(s) will most likely be used for bone marrow aspiration and analysis to determine your client's ability to produce blood cells?
1. osteoblastic 2. osteoclastic 3. sternum and part of the pelvis 4. femur
A nurse is caring for a client who is visually impaired. Which of the following is a recommended guideline for communication with this client?
A) Ease into the room without acknowledging presence until the client can be touched. B) Speak in a louder tone of voice to make up for lack of visual cues. C) Explain reason for touching client before doing so. D) Keep communication simple and concrete.