A college student has quit attending classes, isolates self because of hearing voices, and yells accusations at fellow students. Based on this information, which nursing diagnosis should the nurse prioritize?
A. Altered thought processes R/T hearing voices AEB increased anxiety
B. Risk for other-directed violence R/T yelling accusations
C. Social isolation R/T paranoia AEB absence from classes
D. Risk for self-directed violence R/T depressed mood
ANS: B
The nursing diagnosis that must be prioritized in this situation is risk for other-directed violence R/T yelling accusations. Hearing voices and yelling accusations indicate a potential for violence, and this potential safety issue should be prioritized.
You might also like to view...
The patient with metabolic acidosis should be closely monitored for the compensatory condition of:
1. metabolic alkalosis. 2. respiratory acidosis. 3. respiratory alkalosis. 4. thyroid imbalances.
The nurse is caring for a client on the oncology unit who has developed stomatitis during chemotherapy. The nurse would plan which of the following measures to treat this complication?
1. Rinse the mouth with diluted baking soda or saline. 2. Use lemon and glycerin swabs liberally on painful oral lesions. 3. Place the client on NPO status for 12 hours, then resume liquids. 4. Brush the teeth and use nonwaxed dental floss at least twice a day.
A nurse is completing a health history on a client during a routine physical exam. Which of the following questions, which is often omitted, should be asked by the nurse?
a. "How is your family doing?" b. "What problems have you been having?" c. "What health concerns do you have today?" d. "Where do you work and what do you do there?"
A patient with a lung abscess is being discharged from the hospital. What should be included in this patient's discharge instructions?
A. Complete the entire prescription of antibiotics. B. Return to routine activities of daily living. C. Lung abscesses rarely cause other problems once treatment is started. D. Expect symptoms to become worse.