A client is admitted for psychiatric observation after being arrested for breaking windows in the
home of his former girlfriend, who had refused to see him.
His history reveals abuse as a child by a
punitive father, torturing family pets, and one arrest for disorderly conduct. The nursing diagnosis
that should be considered for development is
a. risk for injury.
b. posttrauma syndrome.
c. disturbed thought processes.
d. risk for other-directed violence.
D
The defining characteristics for risk for violence directed at others include a history of being abused
as a child, having committed other violent acts, and demonstrating poor impulse control. The
defining characteristics for the other diagnoses are not present in the scenario.
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A patient is in the intensive care unit to be digitalized. This patient is to be digitalized rapidly. What is the total dose range of digoxin (Lanoxin) for rapid digitalization?
A) 0.75–1.5 mg B) 2.0–2.5 mg C) 3.75–4 mg D) 0.125–0.05 mg
A patient is in a hospice receiving palliative care for lung cancer. The cancer has metastasized to the liver and bones. The patient is experiencing dyspnea. What might the nurse do to help to relive the dyspnea the patient is experiencing?
A) A fluid bolus B) High-flow oxygen to treat low oxygen saturation C) High doses of opioids D) Administer corticosteroids as ordered
An elderly client is admitted with fractured femurs sustained in a motor vehicle accident. Once the client is stabilized, which of the following should the nurse assess in this client?
1. Blood pressure 2. The client's accident history 3. Need for assistance once discharged to home 4. Car insurance carrier
A nurse develops a plan of care for an older adult recently diagnosed with Lewy body dementia. Which functional consequence would be most important to monitor in this older adult?
A) Development of visual hallucinations B) A visual acuity score of 20/30 C) Improved visual acuity after medications for dementia D) Growth of cataracts