The nurse is interviewing a client in crisis to assess the risk for self-harm. The nurse interprets that the client is most at risk for suicide if the client:
1. Exhibits impulsive behavior
2. Exhibits disorganized behavior
3. Has a history of suicide attempts
4. Has an immediate plan for a suicide attempt
4
Rationale: A client who has a specific suicide plan is most at risk for actually committing suicide, especially if the method is highly lethal and available to the client. The client also presents a lethality potential if the client appears disorganized and impulsive. Clients at higher risk for suicide include those with a history of a dual diagnosis of mental illness and substance abuse, a personal or family history of suicide attempts, depression, alcoholism, or psychotic episodes.
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The rationale for documenting and planning the patient's care upon admission is to:
A) Provide continuity of care B) Create a teaching log for family C) Verify staffing D) Provide the patient with information about treatments
The nurse is caring for a patient who received a new diagnosis of cancer. The patient exhibits signs of a sympathetic stress reaction
What signs and symptoms will the nurse assess in this patient consistent with an acute reaction to stress? (Select all that apply.) A) Profuse sweating B) Fast heart rate C) Rapid breathing D) Hypotension E) Inability to interact with others
Based on this priority, what nursing interventions do you need to perform?
What will be an ideal response?
Cells that most commonly active during chronic infections are:
A. lymphocytes, monocytes, and plasma cells. B. polymorphonuclear leukocytes, monocytes, and mast cells. C. complement and bradykinins. D. None of the above.