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.
Client position when assessing jugular vein distention.
This unit is applying smoke to the fuel tank through an adapter and the leak was easily found to be ...
Client files are kept in alphabetical order in locked file cabinets.
As with smoking, drinking alcohol during pregnancy exposes the fetus to potentially toxic substances
Testing client’s ability to identify dull sensation
Prefilled Unit-Dose Systems