Answer to Question 1
Ans: C
The priority nursing diagnosis is Risk for Other-Directed Violence related to alcohol withdrawal. The most common nursing diagnoses for clients experiencing intense anger and aggression are Risk for Self-Directed Violence and Risk for Other-Directed Violence. Although the other answers are possible nursing diagnoses, there is no evidence to support a risk for injury, self mutilation, or delayed development.
Answer to Question 2
Ans: D
The nurse determines that the son has understood the nurse's instructions when he says, If I simplify our home environment, my father may be less agitated. The goal is to reduce environmental stimuli and adapt the environment to the client. Restraints are used only as a last resort. Continuous surveillance is unrealistic. Taking the client out shopping would add to the already intense and highly confusing stimulation.
Nurse examining and measuring hematuria sample from client with a UTI
Aquamatic pad and heating unit provide dry heat treatment to a patient’s arm.
Use a step stool to help an infirm client get on and off the table.
Intervention Model-Response to Client Misconduct
Use face cradle covers to prevent the client’s skin from touching the face cradle upholstery.
Elephant (Loxodonta africana) herd drinking at water hole. Etosha National Park, Namibia.