A client who is severely and persistently mentally ill with bipolar disorder also abuses alcohol. He
comes to the mental health clinic for his lithium level to be tested. The results suggest the client has
not been medication compliant.
The nurse ascertains that the client's lithium was stolen from his
pocket while he was intoxicated and sleeping. This is the third time this has happened. The nursing
diagnosis of highest priority that should be formulated is
a. risk for injury related to frequent intoxication.
b. noncompliance with medication regimen related to denial of illness.
c. ineffective therapeutic regimen management related to situational obstacles (theft
of medication).
d. decisional conflict related to unpleasant side effects of medication.
C
Ineffective therapeutic regimen management related to situational obstacles is a viable diagnosis. It
recognizes the client's inability to regulate and integrate the medication program as a result of the
theft of the medication. Options A and B: The client has not made an informed decision not to
adhere to the therapeutic recommendation, and the client is not denying illness. Option D: Risk for
injury is not the priority at this time, and no data support decisional conflict.
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A person aged 84 would be classified, according to current systems, as:
a) young old b) middle old c) old old d) very old
A daughter of an older adult patient who has just returned from surgery is distressed about her father's pale, cold hands and feet. What is the best response by the nurse after covering the pa-tient with an extra blanket?
a. "Don't be concerned. It is quite cold in the operating room. Your dad will be warm in a minute." b. "Older patients like your dad get a little shocky during surgery." c. "When patients have blood loss during surgery, superficial vessels close off tem-porarily, resulting in cold extremities." d. "We are watching the disturbed circula-tion in your dad's hands and feet very carefully."
When assessing a patient on PCA therapy, the nurse finds the patient to be somnolent, with minimal or no response to physical stimulation, scoring a 4 on the sedation scale. What is the recommended intervention in this situation?
A) Stop the medication infusion immediately and notify the primary care provider; prepare to administer oxygen and a narcotic antagonist, such as naloxone (Narcan). B) Stop the PCA infusion, check the medication level, and restart the infusion at a lower dose. C) Stop the PCA infusion, increase the frequency of sedation and respiratory rate monitoring to every 15 minutes, arouse the patient, and encourage deep breathing. D) Stop the infusion and report the incident to the nurse manager in charge; follow the protocol of oxygen and naloxone administration.
An appropriate nursing diagnosis for a patient who manifests a psychological problem through frequent expressions of unfounded or excessive guilt or shame, states that he is unable to deal with situations, and has a hesitation to try new things would be:
a. Hopelessness b. Powerlessness c. Ineffective coping d. Chronic low self-esteem