A client diagnosed with schizophrenia spectrum disorder tells a nurse about voices commanding him to kill the president. Which is the priority nursing diagnosis for this client?
1. Disturbed sensory perception
2. Altered thought processes
3. Risk for violence: directed toward others
4. Risk for injury
3
Rationale: The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices commanding him to kill someone is at risk for other-directed violence. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions.
You might also like to view...
An adult resident of an assisted living facility has not responded appreciably to bulk-forming laxatives so the primary care provider has prescribed bisacodyl
The nurse who oversees the care at the facility should know that this drug may be administered by what routes? Select all that apply. A) Oral B) Intravenous C) Subcutaneous injection D) Suppository E) Intramuscular injection
Medicaid pays for home care services for people who have low incomes. Some states require Medicare enrollment to be eligible for Medicaid. This program is administered by the:
a. federal government. b. city government. c. state government. d. county government.
A hurricane in Texas left thousands of people injured and homeless. The Strategic National Stockpile was deployed and supplies were used to treat these patients by nurses from local hospitals
The patients have now successfully been transported to hospitals or shelters, and the nurses are prepared to bring their support to a successful conclusion. The removal and retrieval of the remnants of the 12-hour push packs will be completed by: 1. The Technical Advisory Response Unit. 2. The nurses who provided emergency care to the hurricane victims. 3. The vendors. 4. The Centers for Disease Control personnel.
The nurse is tracing the digestive pathway for a group of nursing students. The nurse educator is reviewing the major organs of the gastrointestinal tract and the function of each
Based on information provided, what is the correct response by the student nurse of the function of the salivary gland of the gastrointestinal tract? A) It senses the temperature and texture of food and is also involved with the mixing of food with saliva. B) Food is mixed with gastric juices and churned until it is in a semiliquid form called chyme. C) Contraction results in continuation of the act of swallowing and pushes the food into the esophagus. D) Secretion helps in moistening the food, making it easier to swallow and preventing oral infections.