The nurse identifies the following client problems: ataxia and falling due to intoxication, skin le-sions associated with psoriasis, shyness of long-standing duration, hearing voices saying pleasant things for 3 months
Which problem should take priority during the 12 hours immediately following admission?
1. Ataxia and falling
2. Psoriatic skin lesions
3. Shyness
4. Hearing voices
ANS: 1
The condition that presents the greatest threat to the client's physical safety (option 1) is of prior-ity importance. The order of importance of intervention is placed in the following sequence: safety, health, intrapersonal problems and needs, and interpersonal problems and needs.
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