The nurse has requested an order to place a patient on suicide ...

[Awilson837]

The nurse has requested an order to place a patient on suicide watch. Which data noted in the health assessment led the nurse to this conclusion? (Select all that apply.)
 
  a. Threats of killing oneself
  b. Chronic pain
  c. History of prior suicide attempt
  d. Loneliness
  e. Stable heart rhythm

Question 2

A patient is admitted to the emergency room after experiencing severe chest pain and difficulty in taking deep breaths. The patient anxiously tells the nurse, My father died suddenly of a heart attack at the age of 52. I'm so scared.
 
  Which nursing diagnoses are appropriate for this situation? (Select all that apply.)
  a.
  Acute pain
  b.
  Fear
  c.
  Risk for aspiration
  d.
  Risk for infection

[vboyd24]

Answer to Question 1

ANS: A, B, C, D
Risk factors may be environmental, physical, psychological, or situational concerns. The nurse is concerned that the patient may be at risk for suicide. Verbal statements by the patient, physical illness such as chronic pain, prior attempts to commit suicide, and a lack of social interaction are potential causes for the act of suicide. A stable heart rhythm would not be a safety concern.

Answer to Question 2

ANS: A, B
One patient may have several problems simultaneously, requiring the nurse to understand the potential relatedness of signs and symptoms from various body systems. The nurse combines an understanding of pathophysiology, normal structure and function, disease processes, and symptomatology to accurately cluster data. The patient is reporting severe chest pain with an inability to take deep breaths. The nursing diagnostic label of acute pain is appropriate. Being scared is a defining characteristic of the nursing diagnosis of fear. The patient is not at risk for aspiration or infection based on the data presented.