Gerald has a co-occurring diagnosis of alcoholism and bipolar disorder. He was brought to the hospital by two policemen who had broken up a fight Gerald had gotten into in a neighborhood bar.
Gerald is intrusive and verbose about having diplomatic immunity and his pressing need to tour the bi-state area to promote his bid for the presidency. Gerald has had multiple admissions to the hospital's psychiatric unit, and he has almost always experienced alcohol withdrawal syndrome immediately following his previous admissions. Which of the following would be a nursing management priority for Gerald at this time?
A) Administering mood-stabilizing medications to control his delusional thinking because doing so will curtail his desire to drink
B) Taking baseline vital signs and then monitoring them on an ongoing basis to ascertain if Gerald is exhibiting early signs of alcohol withdrawal
C) Suggesting that Gerald refrain from being intrusive and annoying others with his constant chatter about his delusional thinking
D) Referring Gerald to an outpatient community substance abuse treatment center because his addiction has to be adequately addressed before his bipolar problems can be effectively treated
Question 2
A client suddenly jumps up from the chair and begins yelling and cursing at the nurse. The best response by the nurse would be:
A) I can see that you need attention; you should calmly ask for what you want.
B) I don't want to hear that kind of language; don't ever do that again.
C) I will limit your smoking privileges if you can't control yourself.
D) You seem angry. Tell me more about how you're feeling.
Skin signs are objective evidence of an illness or disorder. They can be seen, measured, or felt.
NANDA international nursing diagnosis 2
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