Which nursing action would best promote the psychiatric stabilization of a patient who is both confused and agitated when found wandering barefoot in freezing weather?
a. Place the patient on frequent observation to assess both overall status and potential for harm.
b. Anticipate the inclusion of medication therapy in the patient's therapeutic plan of care.
c. Interview the patient to obtain information regarding the identification of family and/or caregiver.
d. Notify social services that the patient will be in need of both physical and social support resources.
A
The priority nursing intervention for such a patient on the inpatient unit would include measures that prevent harm to self or others.
You might also like to view...
A nurse is assessing a teenaged client who had an accident in a car race. The client's father reveals that the client has also started drinking and using drugs. The nurse can categorize the client in which developmental phase?
A) Cognitive development B) Middle adolescence C) Psychosocial development D) Late adolescence
A client was extremely upset about her prognosis. The nurse looked the client directly in the eye while holding her hand and reassured her by saying, "You're going to be alright
You can get through this." The client's husband was also present when the nurse reassured his wife. When the wife died, the husband sued the nurse for breach of contract. On what basis can the husband win his case? A. The nurse should have avoided reassurance, because the client took the reassurance as a promise of the outcome. B. The nurse should have given better care to help ensure that the wife survived her treatment. C. The nurse should have read the wife's medical record to determine her prognosis before reassuring her. D. The nurse should have reassured the wife only when they were alone, without the husband knowing what was said.
A patient speaks minimal English. What should you do until a translator arrives?
A. Sit quietly reviewing the patient's file. B. Speak slowly and simply. C. Speak loudly and slowly. D. Use gestures and exaggerated facial expressions.
The patient has bipolar disorder and is in a manic phase. The physician prescribes lithium (Eskalith). The patient's current lithium level is 0.4. What will the nurse expect to assess in this patient?
1. A return to baseline behavior, calm and rational 2. Hyperactivity and pressured speech 3. Signs and symptoms of depression 4. A decrease in manic behavior