A patient is admitted with a diagnosis of bipolar disorder, manic phase, and displays extreme hyperactivity, agitation, talkativeness, and emotional lability. Which is the highest priority nursing diagnosis?
a. Risk for injury related to extreme hyperactivity
b. Disturbed thought processes related to manic state
c. Impaired social interaction related to excessive verbalization
d. Impaired sensory perception related to biochemical alterations
A
This nursing diagnosis deals with patient safety, a primary concern for the psychiatric nurse caring for a patient exhibiting symptoms of mania.
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A nurse is working in an immunization clinic
A new colleague asks, "When is the first dose of the diphtheria, tetanus, and acellular pertussis (DtaP, Daptacel) given?" The nurse knows that this series is started at what age? a. At birth b. 6 weeks c. 3 months d. 1 year
The mother with a history of delivering preterm infants is given an amniocentesis to measure the lecithin/sphingomyelin ratio to detect:
a. Meconium b. Protein level c. Sufficiency of surfactant d. Evidence of adequate perfusion of placenta
The nurse has determined that the assessment data have resulted in a strong inference that the client is suffering from depression. Which of the following client responses to nursing questions best supports the possibility of depression?
(Select all that apply.) 1. "My work environment would depress anyone." 2. "It seems like almost anything can make me cry." 3. "Being here away from my family makes me sad." 4. "I just can't seem to get excited about anything anymore." 5. "The family always thought that my father was depressed." 6. "I like winter because I can just cover up on the couch and sleep."
Which of the following is a common EFM finding when monitoring a preterm fetus?
A. Decreased baseline B. Variable decelerations C. Increased FHR variability