When reviewing the history of a newly admitted patient diagnosed ...

[Pea0909berry]

When reviewing the history of a newly admitted patient diagnosed with severe chronic depression, the nurse is most concerned about patient safety issues when noting:
 
  a. The patient's Axis II includes a diagnosis of mental retardation
  b. Documentation that the patient has been noncompliant regarding medications
  c. The patient's current Global Assessment of Functioning (GAF) Scale rating is 9
  d. Reference to a recent physical injury resulting from the patient's impulsive be-havior

Question 2

An appropriate nursing diagnosis for a patient who manifests a psychological problem through frequent expressions of unfounded or excessive guilt or shame, states that he is unable to deal with situations, and has a hesitation to try new things would be:
 
  a. Hopelessness
  b. Powerlessness
  c. Ineffective coping
  d. Chronic low self-esteem

[maaaaaaaaaa]

Answer to Question 1

ANS: C
The Global Assessment of Functioning (GAF) Scale is one of the tools use to assess patient functioning and possible prognosis. It is coded on a numerical continuum, with 1 indicating little danger and 10 indicating severe or persistent danger, and possible suicidal potential. Mental deficiency may contribute to issues of safety but it is not a significant risk factor. Noncompliance may contribute to the patient's depression but it is not the greatest concern identified. Although past history is considered a predictor of future behavior, this is more related to the safety of others than to the patient.

Answer to Question 2

ANS: D
The behaviors mentioned in the situation are congruent with criteria for the diagnosis of chronic low self-esteem. The patient's symptoms go beyond powerlessness. Hopelessness does not involve feelings of guilt and shame. The data is not consistent with a diagnosis of ineffective coping.

[Pea0909berry]

Gracias!

[rleezy04]

Excellent