A client diagnosed with paranoid schizophrenia has a history of aggravated assault. A nurse assigns Risk for other-directed violence as the client's priority nursing diagnosis.
Based on this diagnosis, which would be an appropriate, correctly written outcome for this client? A. The client will not verbalize anger or hit anyone.B. The client will verbalize anger rather than hit others.C. The client will not inflict harm on others during this shift.D. The client will be restrained if verbal or physical abuse is observed during this shift.
Question 2
For select clients, physical restraint is considered to be a beneficial intervention. This is based on which premise?
A. Clients with poor boundaries do not respond to verbal redirection, and they need firm and consistent limit setting.B. Clients with limited internal control over their behavior need external controls to prevent harm to themselves and others.C. Clients with antisocial tendencies need to submit to authority.D. Clients with behavioral dysfunction need behavioral interventions.
Schizophrenia
Application of an ostomy bag or pouch: B, An ostomy nurse applying an ostomy bag to a stoma;
Weber test: Place the base of the tuning fork on top of the client’s head.
Use a step stool to help an infirm client get on and off the table.
Example of simplified note for one-time client.
The client is positioned for the examination