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Author Question: A 26-year-old woman who gave birth to a normal newborn 1 month ago reports she simply cannot cope ... (Read 26 times)

ereecah

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A 26-year-old woman who gave birth to a normal newborn 1 month ago reports she simply cannot
  cope with her situation. She is unable to sleep, eats little, and says she feels like a failure because
  she can't take care of her baby.
 
  She has been thinking her baby is the devil's spawn and the root of
  her problems. She sits and stares into space, her face a worried, perplexed mask. The priority nursing
  diagnosis for the client is
  a. disturbed sleep pattern.
  b. disturbed thought processes.
  c. situational low self-esteem.
  d. risk for other-directed violence.

Question 2

The nurse is sitting with a client diagnosed as having schizophrenia, disorganized type, who starts to
  laugh uncontrollably, although the nurse has not said anything funny. The nurse should say
 
  a. Please share the joke with me..
  b. Why are you laughing?
  c. I don't think I said anything funny..
  d. You're laughing. Tell me what's happening..



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bimper21

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Answer to Question 1

D
When the mother with depression of postpartum onset has ruminations or delusional thoughts about
the infant, the risk for harming the infant is increased; thus it becomes the priority diagnosis. The
other diagnoses are relevant but are of lower priority.

Answer to Question 2

D
The client is likely laughing in response to inner stimuli such as hallucinations or fantasy. Moller
suggests focusing on the hallucinatory clue (the client's laughter) and eliciting the client's
observation. The other options are less useful in eliciting a response. Option A: No joke may be
involved. Option B: Why questions are difficult to answer. Option C: The client is probably not
focusing on what the nurse said in the first place.





 

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