A client admitted to the inpatient unit has a diagnosis of schizophrenia, residual type. The nursing diagnosis that has the highest priority for this client is:
1. Disturbed Thought Process
2. Impaired Social Interaction
3. Impaired Verbal Communication
4. Risk for Violence: Self-Directed or Other-Directed
4
Rationale: Risk for Violence: Self-Directed or Other-Directed is the nursing diagnosis that is most closely related to patient safety, which is the highest priority in nursing care of any client. Impaired Social Interaction, Disturbed Thought Processes, and Impaired Verbal Communication represent accurate and important nursing diagnoses, but client safety is the highest priority for planning care.
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A patient who has been taking metformin (Glucophage) for a year is seen in the clinic and has all of the following laboratory results. Which result does the nurse report to the prescriber immediately?
a. Blood urea nitrogen (BUN) 38 mg/dL b. Red blood cell (RBC) count 4.1 million/mm3 c. Random blood glucose level 135 mg/dL d. Alkaline phosphatase 40 international units per liter
The growing multiculturalism of American society can contribute to ethnicity conflicts when
a. Cultural standards are congruent with professional standards. b. Cultural traditions within an ethnic group align with those of the community. c. Ethnic groups overburden the health care system. d. The greater community's values are jeopardized by specific ethnic values.
The Quality and Safety Education for Nurses (QSEN) initiative has identified which key competencies for nurses? Select all that apply
A) Client-centered care B) Teamwork and collaboration C) Evidence-based practice D) Quality improvement E) Correct documentation
On inspection of the client's wound, the nurse notes that it appears infected and has a large amount of exudate. Which of the following is an appropriate dressing for the nurse to select based on this wound assessment?
a. Foam b. Hydrogel c. Hydrocolloid d. Transparent film