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 C

Explanation

A) Allowing the client time alone to sort out feelings may seem supportive, but isolation can be detrimental, especially for someone who has recently attempted suicide. Social withdrawal can exacerbate feelings of despair and hopelessness. Instead, encouraging engagement with others and structured activities is often more beneficial.

B) Avoiding discussions about subjects that upset the client can lead to avoidance coping and prevent the client from processing important emotions. While it’s important to be sensitive to triggers, avoiding difficult topics may hinder therapeutic progress. Open dialogue is essential for healing and understanding.

C) Encouraging activities that allow the client to exert control over their environment is an effective intervention. This approach helps rebuild a sense of agency and empowerment, which is crucial for clients who may feel helpless after experiencing significant losses. Engaging in structured activities can foster a sense of accomplishment and stability, which can be particularly beneficial for someone recovering from a suicide attempt.

D) Encouraging the client to interact with persons who are recovering from depression can provide valuable support and understanding; however, this may not be the most immediate intervention. The client may still be in a fragile state, and facilitating control through structured activities might be a more effective way to build confidence and a sense of community before introducing peer interactions.

A. Show the client the unit. B. Offer medication to the client. C. Explain the nurse's role to the client D. Read to the client his rights.

Correct Answer is C

Explanation

A) Showing the client the unit can be helpful for orientation, but it may not address the client's immediate emotional state. Since the client is exhibiting paranoia and sitting quietly, they might not feel safe or ready to engage in a tour.

B) Offering medication to the client may be appropriate later, but it does not address the client's current need for safety and trust. If the client is feeling paranoid, they might be suspicious of medications offered right away.

C) Explaining the nurse's role to the client is the first and most important intervention. This helps to establish trust and reduce anxiety, as it clarifies the nurse's intentions and reassures the client that they are there to provide support. Building rapport is crucial in dealing with a client exhibiting paranoia.

D) Reading the client their rights is important but may feel overwhelming to a client who is already anxious or paranoid. It’s more effective to first build a connection and establish a sense of safety before discussing rights or other formalities.

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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

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. While approaching the client, which intervention should the nurse implement first?

Correct Answer is C

Explanation

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