In a sad voice, a patient tells the nurse of the recent deaths of a spouse of 50 years and their adult child in an automobile accident. The patient has no other family and only a few friends in the community. What is the priority nursing diagnosis?
a. Spiritual distress, related to being angry with God for taking the family
b. Risk for suicide, related to recent deaths of significant others
c. Anxiety, related to sudden and abrupt lifestyle changes
d. Social isolation, related to loss of existing family
ANS: B
The patient appears to be experiencing normal grief related to the loss of the family; however, because of age and social isolation, the risk for suicide should be determined and has high priority. No defining characteristics exist for the diagnosis of anxiety or spiritual distress. Risk for suicide is a higher priority than social isolation.
You might also like to view...
You are discharging a 4-year-old patient from the emergency department. The patient was seen for an insect bite that became swollen and reddened and warm and painful to touch
The patient's vital signs are all within normal range for age. While giving discharge instructions to the patient's father, you are asked why the child is not going to get antibiotics for the infected insect bite. What would be your best response? A) "This is a local inflammatory response to the insect bite; it is not an infection so antibiotics will not help." B) "I am sure the doctor knows what he is doing." C) "You don't need to worry; your son will be fine." D) "Infection is not the same as inflammation. What your son has is inflammation."
Nipple confusion results when:
1. breastfeeding babies receive supplementary bottle feedings. 2. the baby is weaned too abruptly. 3. pacifiers are used before breastfeeding is established. 4. when twins are breastfed together.
The nurse is reviewing the different types of enemas with a group of nursing students. What would be the best description by a student nurse of a carminative enema?
A) Consists of a small amount of olive or cottonseed oil, given to protect or soothe the mucous membrane of the colon. B) Introduces enough fluid into the colon to soften feces, stimulate peristalsis, and produce a bowel movement that empties the rectum and lower colon C) Medication is inserted into the rectum in combination with a small amount of oil or saline to reduce its irritating effect and to lessen the client's desire to expel it. D) Given to stimulate peristalsis so that flatus is expelled from the intestine
A Hispanic toddler has pneumonia. The nurse notices that the parent consistently feeds the child only the broth that comes on the clear liquid tray. Food items, such as Jell-O, Popsicle, and juices are left. Which statement would best explain this?
a. Parent is trying to feed child only what child likes most. b. Parent is trying to restore normal balance through appropriate "hot" remedies. c. Hispanics believe the "evil eye" enters when a person gets cold. d. Hispanics believe an innate energy, called chi, is strengthened by eating soup.