A client is admitted to the behavioral health unit in the hospital after the police pick the client up for running in the streets naked and saying that he is the emperor of a mystical land. The nursing diagnosis is Altered Thought Processes
A realistic and measurable short-term goal for this client would be which of the following goals? a. Within 3 days, the client will be able to stay in a reality-based conversation for 30 minutes.
b. By discharge, the client will have a different perception of his appearance and role.
c. Within 1 day, the client will communicate coherently.
d. By discharge, the client will realize that even emperors are expected to wear clothes.
A
The admission information regarding the client running in the streets naked or voicing delusions of grandeur indicate that the client is out of touch with reality. The most appropriate outcome to address the client's thought process is that the client would be able to stay in a reality-based conversation for 30 minutes. This outcome is both measurable and realistic.
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Which nursing action demonstrates the correct technique to remove a grossly soiled gown when leaving isolation?
1. Grasp the sleeve of the dominant arm, and remove it with a gloved hand. 2. Release the neck ties of the gown and allow the gown to fall forward. 3. Untie the strings at the neck first. 4. Untie the strings at the waist first.