The nurse is planning care for a client admitted to the psychiatric unit with a diagnosis of paranoi...

The nurse is planning care for a client admitted to the psychiatric unit with a diagnosis of paranoid schizophrenia. Which nursing diagnosis should receive the highest priority?

A.Risk for self- or other-directed violenc
B.Imbalanced nutrition.
C.Ineffective coping.
D.Impaired verbal communication.

进入题库练习

参考答案: A

参考解析: Because of such factors as suspiciousness, anxiety, and hallucinations, the client with paranoid schizophrenia is at risk for violence toward himself or others. The other options are also appropriate nursing diagnoses but should be addressed after the safety of the client and those around him is established.

你可能感兴趣的试题

1 单选题 1分

A client who agreed to become an organ donor is pronounced dead. What is the most important factor in selecting a transplant recipient?

A.Blood relationship.
B.Sex and siz
C.Compatible blood and tissue types.
D.Nee

2 单选题 1分

The nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. She's in her 30s and has two young children. Although she's worried about her future, she seems to be adjusting well to her diagnosis. What should the nurse do to support her coping?

A.Tell the client's spouse or partner to be supportive while she recovers.
B.Encourage the client to proceed with the next phase of treatment.
C.Recommend that the client remain cheerful for the sake of her children.
D.Refer the client to the American Cancer Society's Reach for Recovery program or another support program.

3 单选题 1分

A 19-year-old primigravida is admitted to the labor and delivery unit in labor. She's 2 cm dilated and 50% effaced, and the fetal head is at 0 station. She's having moderately strong 40-second contractions every 5 minutes. She seems rather anxious and becomes very tense during each contraction. When the client asks for pain relief, what should the nurse do next?

A.Determine the source of her anxiety and institute interventions to help her relax.
B.Immediately check the physician's order and give her the analgesic ordere
C.Inform her that the neonate's head isn't down far enough just yet but that, as soon as it is, medication will be given.
D.Tell her that her contractions are only moderately strong and that she should wait until later to take medication.