A client has been admitted to the detoxification unit after binge ...

[ereecah]

A client has been admitted to the detoxification unit after binge drinking. Even though the client is not currently intoxicated, he is combative and exhibits altered thought processes. Which nursing diagnosis would be the priority?
 
  A) Risk for Injury related to effects of alcohol abuse
  B) Risk for Self-Mutilation related to alcohol withdrawal and altered thought processes
  C) Risk for Other-Directed Violence related to alcohol withdrawal
  D) Risk for Delayed Development related to chronic effects of alcohol intoxication

Question 2

A nurse is caring for a family whose older father with dementia is living in their home. The nurse has instructed the family about how to decrease the father's agitation.
 
  The nurse determines that the son has understood the instructions when he states which of the following?
 
  A) Restraints can help reduce my father's agitation.
  B) I should place my father in the bedroom with me so I can watch him more closely.
  C) It's important that he gets out shopping with me or my wife.
  D) If I simplify our home environment, my father may be less agitated.

[sarahccccc]

Answer to Question 1

Ans: C
The priority nursing diagnosis is Risk for Other-Directed Violence related to alcohol withdrawal. The most common nursing diagnoses for clients experiencing intense anger and aggression are Risk for Self-Directed Violence and Risk for Other-Directed Violence. Although the other answers are possible nursing diagnoses, there is no evidence to support a risk for injury, self mutilation, or delayed development.

Answer to Question 2

Ans: D
The nurse determines that the son has understood the nurse's instructions when he says, If I simplify our home environment, my father may be less agitated. The goal is to reduce environmental stimuli and adapt the environment to the client. Restraints are used only as a last resort. Continuous surveillance is unrealistic. Taking the client out shopping would add to the already intense and highly confusing stimulation.