A confused patient is restless and continues to try to remove the oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient?
a. Risk for injury: Check on patient every 15 minutes.
b. Risk for suffocation: Place "Oxygen in Use" sign on door.
c. Disturbed body image: Encourage patient to express concerns about body.
d. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter.
ANS: A
The priority nursing diagnosis is Risk for injury. This patient could cause harm to self by interrupting the oxygen therapy or by damaging the urethra by pulling the urinary catheter out. Before restraining a patient, it is important to implement and exhaust alternatives to restraint. Alternatives can include more frequent observations. This patient may have deficient knowledge; educating the patient about treatments could be considered as an alternative to restraints. However, the nursing diagnosis of highest priority is risk for injury. This scenario does not indicate that the patient has a disturbed body image or that the patient is at risk for suffocation.
You might also like to view...
The nurse assists with admission of a patient to the hospital with pancreatitis and a history of alcohol abuse. Why is it important for the nurse to observe the patient for agitation, tremors, and hallucinations?
a. These symptoms indicate possible cirrhosis of the liver. b. These are symptoms of alcohol withdrawal. c. Patients with a history of alcohol abuse are at risk for mental illness. d. The patient may be using alcohol in the hospital setting.
The Harrison Act of 1914 prohibited the:
a. sale of alcohol to minors b. manufacture of designer drugs c. sale of narcotics and cocaine without prescription d. use of ether as an inhalant or hospital anesthetic
A newly admitted patient is profoundly depressed, mute, and motionless. The patient has refused to bathe and eat for a week. Which score would be expected on the patient's global assessment of functioning?
a. 100 b. 80 c. 50 d. 10
The nurse is teaching a class to women who were recently diagnosed with benign breast disease (BBD), commonly known as fibrocystic breast disease. One of the participants reports increased swelling, pain, and pressure in her breasts just before menstruation. What is the best response by the nurse?
1. "It's best to make an appointment with an oncologist." 2. "The pain may be caused by thinning of the normal breast tissue." 3. "Consider asking your healthcare provider about adding a mild diuretic to your regimen." 4. "Breast swelling and pressure are expected symptoms, but pain is abnormal and should be evaluated by your physician."