The nurse is caring for a client who is experiencing auditory hallucinations. Which is the priority nursing diagnosis for this client?
A) Disturbed Thought Processes
B) Individual Ineffective Coping
C) Impaired Verbal Communication
D) Risk for Violence, Self-Directed or Other-Directed
Answer: D
Maintaining a safe environment is the priority diagnosis. Although the client has impaired thought processes, this is not the priority diagnosis at this time. Individual Ineffective Coping and Impaired Verbal Communication are also correct diagnoses, but the key word here is "priority," and this client has a potential or risk for harm to self or others.
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The nurse is caring for a child with a spinal cord injury and providing instruction to the parents on promoting skin integrity. Which response from the mother indicates a need for further teaching?
A) "I need to monitor his skin at least twice a week." B) "I must monitor skin affected by his adaptive equipment." C) "He must change positions frequently." D) "We must avoid harsh cleaning products."
A client has just lost her second baby to preterm complications. The best therapeutic response by the nurse is:
A) "I know how you feel. I have children of my own." B) "I am so sad for you. I'll stay with you for a while if you need to talk." C) "Didn't your doctor advise you about genetic counseling?" D) "Don't be so sad. You can always try again."
The nurse is caring for a client who is experiencing inflammation. Which symptoms would the nurse expect to find upon assessment?(Select all that apply.)
1. Itching 2. Redness 3. Pain 4. Swelling 5. Hyperglycemia
Rolling the arm away from the body is called external rotation.
Answer the following statement true (T) or false (F)