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.
Weber test: Place the base of the tuning fork on top of the client’s head.
A functional renal unit.
A hot stone placed under the client’s neck.
Testing the Achilles tendon reflex with client in a sitting position
Elephant (Loxodonta africana) herd drinking at water hole. Etosha National Park, Namibia.
form unit