Author Question: A nurse documents: Patient is mute, despite repeated efforts to elicit speech. Makes no eye contact. ... (Read 47 times)

Jramos095 · **on:** Jul 19, 2018

A nurse documents: Patient is mute, despite repeated efforts to elicit speech. Makes no eye contact. Is inattentive to staff. Gazes off to the side or looks upward rather than at the speaker. Which nursing diagnosis should be considered?

a. Defensive coping
b. Decisional conflict
c. Risk for other-directed violence
d. Impaired verbal communication

Question 2

A nurse performing an assessment interview for a patient with a substance use disorder decides to use a standardized rating scale. Which scales are appropriate? Select all that apply.

a. Addiction Severity Index (ASI)
b. Brief Drug Abuse Screen Test (B-DAST)
c. Abnormal Involuntary Movement Scale (AIMS)
d. Cognitive Capacity Screening Examination (CCSE)
e. Recovery Attitude and Treatment Evaluator (RAATE)

aloop · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

ANS: D
The defining characteristics are more related to the nursing diagnosis of Impaired verbal communication than to the other nursing diagnoses.

Answer to Question 2

ANS: A, B, E
Standardized scales are useful for obtaining data concerning substance use disorders. The ASI, B-DAST, and RAATE are scales related to substance abuse. The AIMS assesses involuntary movements associated with antipsychotic medications. The CCSE assesses cognitive function.