A patient is hospitalized after an arrest for breaking windows in the home of a former domestic partner. The history reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct
Which nursing diagnosis has priority?
a. Risk for injury
b. Posttrauma response
c. Disturbed thought processes
d. Risk for other-directed violence
ANS: D
The defining characteristics for Risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. The defining characteristics for the other diagnoses are not present in this scenario.
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What is the term for physical expression of anxiety by an individual in ways such as nausea or headaches?
a. Compensation b. Somatization c. Denial d. Fantasy
The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process?
A) Low heart rate B) Elevated blood pressure C) Rapid respiration D) Subnormal temperature
The client delivered her second child 1 day ago. The client's temperature is 101.4° F, her pulse is 100, and her blood pressure is 110/70. Her lochia is moderate, serosanguinous, and malodorous. She is started on IV antibiotics
The nurse provides education for the client and her partner. Which statement indicates that teaching has been effective? 1. "This condition is called parametritis." 2. "Gonorrhea is the most common organism that causes this type of infection." 3. "My Beta-strep culture's being positive might have contributed to this problem." 4. "If I had walked more yesterday, this probably wouldn't have happened."
A large amount of data related to hypertension rates is collected in a community. The data is analyzed. What is the next step in the surveillance process?
a. Collecting data from multiple valid sources b. Evaluating the impact on the surveillance system c. Interpreting the data and disseminating it to decision makers d. Asking political officials to finance a hypertension clinic