A client has a co-occurring diagnosis of alcoholism and bipolar disorder. He was brought to the emergency department by two policemen who had broken up a fight that the client had gotten into in a neighborhood bar
The client is intrusive and verbose about having diplomatic immunity and his pressing need to tour the bistate area to promote his bid for the presidency. The client has had multiple admissions to the hospital's psychiatric unit, and he has almost always experienced alcohol withdrawal syndrome immediately after his previous admissions. Which of the following would be a priority for this client?
A) Administering prescribed mood-stabilizing medications to control his delusional thinking because doing so will curtail his desire to drink
B) Taking baseline vital signs and then monitoring them on an ongoing basis to ascertain if the client is exhibiting early signs of alcohol withdrawal
C) Suggesting that client refrain from being intrusive and annoying others with his constant chatter about his delusional thinking
D) Referring the client to an outpatient community substance abuse treatment center because his addiction has to be adequately addressed before his bipolar problems can be effectively treated
B
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The nurse caring for a client with a closed head injury gathers the following data: pupils dilated and nonresponsive bilaterally, no response to vigorous stimuli, absence of corneal reflex, absence of respiratory initiation when carbon dioxide
levels elevate, and decrease in blood pressure. The nurse anticipates a diagnosis of: 1. Increased intracranial pressure. 2. Brain death. 3. Cerebrovascular accident. 4. Intracranial hemorrhage.
A woman at 28 weeks' gestation is asked to keep a fetal activity diary and to bring the results with her to her next clinic visit
One week later, she calls the clinic and anxiously tells the nurse that she has not felt the baby move for over 30 minutes. The most appropriate initial comment by the nurse would be: 1. "You need to come to the clinic right away for further evaluation." 2. "Have you been smoking?" 3. "When did you eat last?" 4. "Your baby might be asleep."
When caring for the child with Kawasaki disease, what should the nurse know to provide safe and effective care?
a. Aspirin is contraindicated. b. The principal area of involvement is the joints. c. The child's fever is usually responsive to antibiotics within 48 hours. d. Therapeutic management includes administration of gamma globulin and salicylates.
Which of the following nursing diagnoses is most appropriate for the client with acute systolic heart failure?
1. Excess Fluid Volume 2. Disturbed Body Image 3. Imbalanced Nutrition: more than body requirements 4. Ineffective Airway Clearance