A young man has been brought to the emergency department (ED) by ...

[stephzh]

A young man has been brought to the emergency department (ED) by police after exhibiting bizarre and violent behavior on the patio outside a restaurant. Upon questioning, the man's girlfriend admits that he had been smoking PCP with his friend.
 
  While in the ED, the man continues to exhibit signs of PCP-induced psychosis and has required physical restraints. What nursing outcome should the nurse prioritize in the care of this patient?
 
  A) The client will be physically safe and without injury.
  B) The client will demonstrate appropriate social skills.
  C) The client will establish a balance of rest, sleep, and activity.
  D) The client will verbalize acceptance of responsibility for his behavior.

Question 2

A 47-year-old male has been admitted to the hospital after being found unconscious in a park. Upon regaining consciousness, he admits to heavy alcohol use over many years.
 
  Assessment reveals a low body mass index, low electrolyte levels, and impaired skin integrity. Vital signs are within normal ranges. What nursing diagnosis should be prioritized in the care of this client?
 
  A) Risk for injury related to chronic alcohol intake
  B) Deficient knowledge regarding the effects of alcohol intake
  C) Imbalanced nutrition: less than body requirements related to chronic alcohol intake
  D) Ineffective coping related to effects of chemical use

[Bison]

Answer to Question 1

Ans: A
While the client is actively psychotic and restrained, the need for safety is paramount and would be prioritized over establishing healthy routines, taking responsibility, or demonstrating social skills.

Answer to Question 2

Ans: C
High alcohol intake is associated with malnutrition, which can result in low electrolyte levels, low BMI, and impaired skin integrity. This diagnosis is of more immediate concern than the client's coping, knowledge, or future risk for injury.

[stephzh]

TYSM

[kishoreddi]

Excellent