A client is admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt. Which nursing problem has the highest priority?

Impaired comfort.

Risk for injury.

Ineffective breathing pattern.

Ineffective coping.

Answer and Explanation

The Correct Answer is C

A) Impaired comfort is a relevant concern, but it is not the highest priority in the context of a potentially life-threatening situation such as aspiration of a caustic material. While comfort is important, it is secondary to immediate safety and physiological needs.

B) Risk for injury is a general concern in many situations, but in this specific case, it does not address the acute medical implications of the aspiration of caustic material. While injury could occur, the focus should be on the immediate effects of the incident.

C) Ineffective breathing pattern is the highest priority nursing problem. Aspiration of caustic material can lead to severe respiratory complications, including airway obstruction, chemical pneumonitis, and other respiratory distress. Ensuring the client has adequate ventilation and monitoring for signs of respiratory distress are critical nursing interventions that take precedence over other concerns.

D) Ineffective coping is important to address, particularly given the context of a suicide attempt; however, it is not as immediate as the potential life-threatening consequences of aspiration and ineffective breathing. The client’s physical safety must be prioritized before addressing psychological issues.

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Correct Answer is B

Explanation

A) Advising the client to reschedule until committing to recovery may come across as dismissive and could discourage the client from making positive changes. It’s important to support any intention to improve rather than setting conditions that might lead to feelings of failure or frustration.

B) Supporting the client to list small behavioral changes needed is the best response. This approach empowers the client by encouraging them to take manageable steps toward their goals. Focusing on small changes can enhance the client's confidence and motivation, making the process of leading a healthier lifestyle more achievable.

C) Explaining the specific skills needed to prevent relapse is important, but it may be overwhelming for the client at this stage. The focus should be on fostering a sense of hope and readiness for change rather than diving immediately into complex relapse prevention strategies.

D) Providing teaching on the symptoms of substance use dependence might be relevant, but it may not directly support the client's desire for change. The client is expressing a wish to move forward, so it’s more beneficial to focus on positive actions rather than reiterating the challenges of dependence. Supporting behavioral change aligns better with the client’s expressed intentions.

A. Sit within two feet of the client to enhance the level of safety and security. B. Dim the lights in the room to help the patient feel calm. C. Position a table between the client and the nurse for extra personal space. D. Reduce the noise level in the room by turning off the television and radio.

Correct Answer is D

Explanation

A) Sitting within two feet of the client may enhance feelings of safety and security for some individuals, but for others, it could feel intrusive or overwhelming. Establishing an appropriate personal distance is essential, and too close of a proximity might create discomfort, especially in a mental health setting where clients may already feel vulnerable.

B) Dimming the lights in the room can create a calming atmosphere; however, excessive dimness might hinder visibility and affect communication. While lighting can influence mood, it’s crucial to strike a balance that allows the client to feel comfortable without compromising the ability to engage effectively during the interview.

C) Positioning a table between the client and the nurse may provide a sense of personal space, but it can also create a physical barrier that may hinder open communication and rapport-building. Establishing a connection is important in mental health interviews, and a table might inadvertently foster feelings of separation or defensiveness.

D) Reducing the noise level in the room by turning off the television and radio is the most effective approach to facilitate the interview. A quiet environment minimizes distractions, allowing both the nurse and the client to focus on the conversation. This fosters a safe and supportive atmosphere where the client feels heard and respected, which is crucial for building trust and promoting an effective therapeutic interaction.

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A client is admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt. Which nursing problem has the highest priority?

Nursing Test Bank

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