The patient is confused, is trying to get out of bed, and is ...

[bio_gurl]

The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. Which nursing diagnosis will the nurse add to the care plan?
 
  a. Impaired home maintenance
  b. Deficient knowledge
  c. Risk for poisoning
  d. Risk for injury

Question 2

The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority?
 
  a. Monitor for specific symptoms.
  b. Manage all patients using standard precautions.
  c. Transport patients quickly and efficiently through the elevators.
  d. Prepare for post-traumatic stress associated with this bioterrorism attack.

[tkempin]

Answer to Question 1

ANS: D
The patient's behaviors support the nursing diagnosis of Risk for injury. The patient is confused, is pulling at the intravenous line, and is trying to climb out of bed. Injury could result if the patient falls out of bed or begins to bleed from a pulled line. Nothing in the scenario indicates that this patient lacks knowledge or is at risk for poisoning. Nothing in the scenario refers to the patient's home maintenance.

Answer to Question 2

ANS: B
Manage all patients with suspected or confirmed bioterrorism-related illnesses using standard precautions. For certain diseases, additional precautions may be necessary. The early signs of a bioterrorism-related illness often include nonspecific symptoms (e.g., nausea, vomiting, diarrhea, skin rash, fever, confusion) that may persist for several days before the onset of more severe disease. Limit the transport and movement of patients to movement that is essential for treatment and care. Psychosocial concerns (post-traumatic stress) are important but are not the first priority at this moment.