A patient who has been seen responding to auditory hallucinations earlier in the morning approaches the nurse and shakes his fist, saying, Back off, bitch and then goes into the day room. The nurse follows the patient into the day room.
Which intervention would be best at this time? a. Stay between the patient and the door for easy exit.
b. Stand out of range of possible assault by the patient.
c. Position oneself about 28 inches from the patient.
d. Sit down in a chair near the patient to convey interest.
Question 2
A patient with serious mental illness lives alone in a neighborhood. The patient receives monthly depot medication injections but lately has missed regular clinic appointments, saying, My life is so busy I couldn't find time to come in.
To prevent decompensation and hospitalization, the community mental health nurse should arrange for:
a. a psychosocial rehabilitation program.
b. assertive community treatment (ACT).
c. an appointment with a nurse in private practice.
d. insurance authorization to change to daily oral medication.
The nurse needs to note the source of the patient health history
Position of patient to assess jugular vein distention
ROM exercises on a patient’s wrist: extension.
Gingival enlargement in a patient taking phenytoin.