A 45-year-old woman is admitted to an inpatient mental health facility with the diagnosis of severe depression. She lives by herself and has been very active in her community for many years
During the past 6 months, she has become increasingly withdrawn from her family and friends and was terminated from her job because of excessive absenteeism. When she arrives on the unit, she makes little eye contact with the nurse, has a flat affect, and answers with one or two words. What is the most appropriate nursing diagnosis for this patient? a. Diversional activity, deficient
b. Coping, ineffective
c. Fatigue
d. Hopelessness
D
The complete picture of this client indicates hopelessness as the most accurate nursing diagnosis at this time. The other three options may apply to her at a later time after further evaluation.
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A homeless individual with severe mental illness, anosognosia, and a history of persistent treatment nonadherence is persuaded to come to the day program at the community mental health center
Which intervention should be the team's initial priority? a. Educate him about the importance of treatment adherence. b. Help him obtain employment in a local sheltered workshop. c. Interact regularly and supportively without trying to change him. d. Teach appropriate health maintenance and prevention practices.
The nurse is caring for a patient who fell from a two-story building and was brought to the emergency department by ambulance. Initial findings include asymmetry of the thorax and paradoxical respirations
The nurse would document these findings as what? A) Flail chest B) Barrel chest C) Scoliosis D) Kyphosis
The nurse realizes that in order to share information from a client's medical record with another facility, the client must provide written consent. The primary reason for this requirement is to:
1. Facilitate the exchange of information between appropriate parties 2. Minimize the opportunity for this information to be assessed inappropriately 3. Ensure the client's right to have his medical information regarded as personal and confidential 4. Guarantee that the information will be shared with only those requiring it for cli-ent care purposes
A nurse reports to the treatment team that a patient diagnosed with an antisocial personality disorder has displayed the behaviors below. This patient is detached and superficial during counseling sessions
Which behavior by the patient most clearly warrants limit setting? a. Flattering the nurse b. Lying to other patients c. Verbal abuse of another patient d. Detached superficiality during counseling