The following North American Nursing Diagnosis Association (NANDA) nursing diagnostic stem was developed for a client on an inpatient unit: Risk for injury. What assessment data most likely led to the development of this problem statement?
A. The client is receiving electroconvulsive therapy (ECT) and is diagnosed with Parkinsonism.
B. The client has a history of four suicide attempts in adolescence.
C. The client expresses hopelessness and helplessness and isolates self.
D. The client has disorganized thought processes and delusional thinking.
ANS: A
The nurse should identify that a client receiving ECT and who is diagnosed with Parkinsonism is at risk for injury due to confusion and potential for falls. History of suicide and hopelessness would lead to the development of nursing diagnosis of risk for suicide. Disorganized thoughts and delusional thinking would lead to the development of a nursing diagnosis of altered thought processes.
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