A patient admitted yesterday for injuries sustained while ...

[K@]

A patient admitted yesterday for injuries sustained while intoxicated believes bugs are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis?
 
  a. Ineffective airway clearance
  b. Ineffective coping
  c. Ineffective denial
  d. Risk for injury

Question 2

The client has recently started antidepressant drug therapy. He approaches the nurse complaining of a headache, palpitations, and stiffness in the neck. The most appropriate ac-tion is to
 
  1. notify the physician immediately.
  2. notify the physician when convenient.
  3. give the client two aspirins and monitor his headache and heart rate.
  4. reassure the client that these are common side effects of his medication.

[SomethingSomething]

Answer to Question 1

D
The patient's clouded sensorium, sensory perceptual distortions, and poor judgment predispose a risk for injury. Safety is the nurse's priority. The scenario does not provide data to support the other diagnoses.

Answer to Question 2

1
Headaches, palpitations, changes in levels of consciousness, and stiffness in the neck should be reported to the physician immediately as they are signs of serious side effects.

[K@]

Thank you

[SomethingSomething]

No problemo