What priority assessment area has been noticed by a nurse while working with clients who are experiencing a significant degree of stress?
1. The client's primary physical needs
2. What else is happening in the client's life
3. How the stress has influenced the client's activities of daily living
4. Determining whether the client is thinking about harming self or others
ANS: 4
A priority assessment is to determine if the person is suicidal or homicidal by asking directly. The priority assessment for the client who is experiencing a significant degree of stress is not the cli-ent's physical needs. The nurse should first determine if the client is a danger to self or others. After determining if the client is suicidal or homicidal, the nurse can begin the problem-solving process and assess what else is happening in the client's life. The nurse should first determine if the client is a danger to self or others. Then the nurse can examine the degree of disruption in the person's life, such as in activities of daily living.
You might also like to view...
A patient who has a diagnosis of schizophrenia is likely to have which of the following pathophysiologic effects?
A) Increased dopamine B) Increased serum potassium C) Decreased numbers of glutamate receptors D) Decreased interaction with GABA
A patient has been taking 10 aspirin tablets a day for his arthritis. He comes into the clinic complaining of a ringing in his ears. The nurse, after assessing the patient, tells him:
1. the tinnitus should improve over time. 2. he needs an injection of vitamin K. 3. to stop taking the aspirin and contact his physician for a different prescription. 4. to increase his fluid intake to 3000 mL a day.
When the Type 1 diabetic patient asks why his 7 AM insulin has been changed from NPH insulin to 70/30 premixed insulin, the nurse explains that 70/30 insulin:
1. is absorbed more rapidly into the bloodstream. 2. has no peak action time and lasts all day. 3. makes insulin administration easier and safer. 4. give a bolus of rapid-acting insulin to prevent hyperglycemia after breakfast.
Informed consent means that the patient
A. refuses to consent to treatment. B. is unaware of the risks involved in certain treatments. C. gives permission for care after the procedure is explained. D. may not be left alone in his room.