A patient fearfully runs from chair to chair crying, "They're coming! They're coming!" The patient does not follow the staff's directions or respond to verbal interventions. Which nursing diagnosis has the highest priority?
a. Fear
b. Risk for injury
c. Self-care deficit
d. Disturbed thought processes
ANS: B
A patient experiencing panic-level anxiety is at high risk for injury related to increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Data are not present to support a nursing diagnosis of self-care deficit or disturbed thought processes. The patient may have fear, but the risk for injury has a higher priority.
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A nurse is providing health education to an adolescent newly diagnosed with type 1 diabetes mellitus and her family. The nurse teaches the patient and family that which of the following nonpharmacologic measures will decrease the body's need for insulin?
A) Adequate sleep B) Low stimulation C) Exercise D) Low-fat diet
When a physician writes an order for the nurse to withhold life-saving treatment from a terminally ill client, the nurse is faced with two different choices, each supported by a different ethical principle. This type of conflict is known as
a. covert conflict. b. overt conflict. c. interpersonal conflict. d. intrapersonal conflict.
A woman has been unable to complete a full-term pregnancy because the fertilized ovum failed to implant in the uterus. This is most likely due to a lack of which hormone?
1. Estrogen 2. Progesterone 3. FSH 4. LH
A nurse is caring for a client who questions how mental health and mental illness are defined. Which words should the nurse use to describe the concepts of mental health and mental illness?
A) Rigid and existential B) Multidimensional and culturally defined C) Universal and unchanging D) Unidimensional and fixed