问题 单项选择题

The nurse is planning care for a client admitted to the psychiatric unit with a diagnosis of paranoid schizophrenia. Which nursing diagnosis should receive the highest priority ?()

A.Risk for self- or other-directed violence.

B.Imbalanced nutrition.

C.Ineffective coping.

D.Impaired verbal communication.

答案

参考答案:A

解析:

Because of such factors as suspiciousness, anxiety, and hallucinations, the client with paranoid schizophrenia is at risk for violence toward himself or others. The other options are also appropriate nursing diagnoses but should be addressed after the safety of the client and those around him is established.

多项选择题
多项选择题 案例分析题

【案例一】:

一般资料:黄某,女性,20岁,护校学生。

案例介绍:上解剖课时,老师要求同学们数人体模型有多少根骨头并记住,黄某和同学数的数总是不一样。从那以后,她看见骨头就爱数,包括吃完的鱼骨头,鸡骨头和猪排骨等,每次多达几十遍,数不清或数不对就重数。黄某明知没有必要,觉得无聊和厌烦,但始终控制不了自己,非常痛苦。老师同学发现后劝她不要这么做,但都无效。三个月前和同学一起逛街,她看见柜台旁的人体模型,突然用手去摸,嘴里念叨:“我要数数,有多少根骨头。”一周前黄某突然明显话多,滔滔不绝,同学反映她说话不连续,晚上也不睡觉,好像很精神。白天四处游荡,说看见学校宣传栏里有数骨头比赛的通知,她一定要好好学习,争取夺第一。

国庆节学校周围摆放了许多鲜花,道路两旁也挂满了彩旗,黄某说:“等着吧,他们马上要给我评奖呢。”

心理咨询师观察了解到的情况:黄某由父母强行带来,说黄某从小就自我要求严格,非常固执,家里的东西都要按她的意见摆放,位置不对或不在原来的地方,她一定要改过来,觉得乱了就要立即整理。目前老师建议其休学看病,而黄某不承认有问题,在家长的强制下来。到心理咨询室。

黄某的精神症状包括()。

A.错觉

B.思维奔逸

C.幻觉

D.关系妄想