A person intentionally overdoses on antidepressant drugs. Which nursing diagnosis has the highest priority?
a. Powerlessness
b. Social isolation
c. Risk for suicide
d. Compromised family coping
ANS: C
This diagnosis is the only one with life-or-death ramifications and is therefore higher in priority than the other options.
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The novice nurse is reviewing the ANA's Code of Ethics for Nurses and its influence on providing patient care. What concept is correct regarding ethical and legal standards?
1. Ethical standards outweigh legal standards. 2. Legal standards outweigh ethical standards. 3. Ethical and legal standards are separate, yet similar. 4. Ethical and legal standards are intertwined, yet distinct.
The patient is admitted with acute pancreatitis. The nurse should:
a. assess pain level because pancreatic pain is unique in character. b. examine laboratory values for low amylase levels. c. expect lipase levels to decrease within 24 hours. d. evaluate C-reactive protein as a gauge of severity.
A patient is ready to begin weaning from mechanical ventilation. The nurse would prepare to assist respiratory therapy with which procedure?
1. Applying a T-tube set 2. Insertion of a short one-way valve 3. Tracheostomy insertion 4. Insertion of a new endotracheal tube
The nurse is reviewing a patient's laboratory results. In the early phase of CKD, the patient is at risk for which electrolyte abnormality?
a. Hyperkalemia b. Hyponatremia c. Hypercalcemia d. Hypokalemia