A nurse documents: "Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker." Which nursing diagnosis should be considered?
a. Defensive coping
b. Decisional conflict
c. Risk for other-directed violence
d. Impaired verbal communication
ANS: D
The defining characteristics are more related to the nursing diagnosis of impaired verbal communication than to the other nursing diagnoses.
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