A person intentionally overdoses on antidepressant drugs. Which nursing diagnosis has the highest priority?

A) Powerlessness
B) Social isolation
C) Risk for suicide
D) Ineffective management of the therapeutic regimen

The nurse would expect to administer an anticoagulant to a patient following which surgery?

A) Hip replacement
B) Hysterectomy
C) Abdominal aorta aneurism (AAA) repair
D) Appendectomy

Which symptoms are expected for a patient diagnosed with schizophrenia who has disorganization?

A) Extremes of motor activity, from excitement to stupor
B) Socially withdrawal and ineffective communication
C) Severe anxiety with ritualistic behavior
D) Highly suspicious, delusional behavior

The nurse is performing a middle ear assessment on a 15-year-old patient who has had a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and landmarks visible. What should the nurse do?

A) Refer the patient for the possibility of a fungal infection.
B) Recognize that these are scars caused from frequent ear infections.
C) Consider that these findings may represent the presence of blood in the middle ear.
D) Be concerned about the ability to hear because of this abnormality on the tympanic membrane.