A hospitalized patient, injured in a fall while intoxicated, ...

[captainjonesify]

A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority?
 
  a. Check the patient every 15 minutes.
  b. Rigorously encourage fluid intake.
  c. Provide one-on-one supervision.
  d. Keep the room dimly lit.

Question 2

A patient admitted yesterday for injuries sustained in a fall while intoxicated believes bugs are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis?
 
  a. Ineffective airway clearance
  b. Ineffective coping
  c. Ineffective denial
  d. Risk for injury

[flannelavenger]

Answer to Question 1

ANS: C
One-on-one supervision is necessary to promote physical safety until sedation reduces the patient's feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes illusions. Oral fluids are important, but safety is a higher priority.

Answer to Question 2

ANS: D
The clouded sensorium, sensory perceptual distortions, and poor judgment increase the risk for injury. Safety is the nurse's priority. The scenario does not provide data to support the other diagnoses.

[captainjonesify]

Excellent

[cam1229]

Gracias!