A 20-year-old college student has stopped attending classes. The student exhibits disorganized thinking, stays in his room all the time, hears voices, and is convinced that a fellow student is spreading untruths about him
The student is admitted to the psychiatric unit and receives a diagnosis of paranoid schizophrenia. Which nursing diagnosis should a nurse assign to this client when planning care?
A) Risk for self-directed violence
B) Ineffective coping
C) Risk for other-directed violence
D) Disturbed thought processes
D
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A 21-year-old woman has been on a low-protein liquid diet for the past 2 months. She has had adequate intake of calories and appears well nourished. After further assessment, what would the nurse expect to find?
a. Poor skin turgor b. Decreased serum albumin c. Increased lymphocyte count d. Triceps skinfold less than standard
A nurse manager learns of a violent situation with a visitor in which an employee was injured. The manager learns the employee has multiple facial lacerations. Which action by the manager would be appropriate?
1. Page a physician who recently left the unit. 2. Administer first aid and take the employee to the emergency room. 3. Call security to assist in the transfer of the employee to the emergency room. 4. Call administration and inform them of the incident.
The nurse is caring for a client who is employed as a manual laborer and works with her hands. Which instruction would be most helpful?
A) Do not return to work until all areas are completely healed. B) Have others assist in tasks involving use of affected arm. C) Wear gloves to prevent injury. D) Check to see if job description can be changed.
Asthma is often underdiagnosed in older adults because:
a. older adults frequently do not have any of the classic signs and symptoms. b. symptoms of asthma are often attributed to normal age-related changes. c. asthma is very uncommon in older adults. d. asthma symptoms are usually very mild in older adults.