Answer to Question 1
3
Rationale: The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices commanding him to kill someone is at risk for other-directed violence. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions.
Answer to Question 2
C
Sleeping later in the morning may disturb circadian rhythms and in this case is adding, rather than reducing, the stress in his life. Going to bed earlier and arising at the usual time alleviates fatigue more effectively. Sedatives may offer some benefit but are a short-term intervention with potential side effects, and other nonpharmacological interventions might work as well or better. Exercise earlier in the evening could induce tiredness and ease the process of falling asleep, but doing so right before bedtime would likely be stimulating and interfere with sleep instead. Alcohol is sedating but is also potentially addictive, and encouraging its use could increase the risk of using alcohol maladaptively as a response to stress in general.
Sunlight consists of a spectrum of colors, visible here in a rainbow.
To check pupillary reflexes the nurse first holds the penlight
Common skin signs are often evidence of an illness or disorder. A scale is a thin, dry flake of ...
Nurse administering enteral nutrition through a feeding tube.
The nurse begins the general survey
Position the client