A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is involuntarily admitted to the psychiatric unit. Which of the following nursing diagnoses has the highest priority?
A) Hopelessness related to recent divorce
B) Ineffective coping related to inadequate stress management
C) Spiritual distress related to conflicting thoughts about suicide and sin
D) Risk for suicide related to a highly lethal plan
D
Feedback: Safety is the priority. The overall goals for the client who is suicidal is to first keep the client safe and later to help him or her to develop new coping skills that do not involve self-harm. Answers A, B, and C are not the priority diagnoses for this client.
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The nurse is using presence to reduce the anxiety of a critically ill patient. What nursing behavior demonstrates an effective use of presence?
A) Staying in the patient's room to complete documentation B) Having a conversation in the patient's room that excludes the patient C) Maintaining eye contact with the patient during explanations D) Focusing on specific nursing care tasks while in the patient's room
A patient with a herniated lumbar disk who reports low back pain with straight leg raising will experience increased pain when you
a. bend the knee. c. dorsiflex the foot. b. lower the leg. d. plantar flex the foot.
The nurse may direct nursing interventions for the homeless to the community as a whole, as well as to individual homeless clients
Indicate whether the statement is true or false
When caring for a patient with a recent TIA, you consider that:
A. long-term antiplatelet therapy is likely indicated. B. this person has a relatively low risk of future stroke. C. women present with this disorder more often than men. D. rehabilitation will be needed to minimize the effects of the resulting neurological insult.