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) Asking the employee what she thinks should happen may put additional pressure on her during an extremely distressing moment. In a crisis, individuals often struggle to think clearly, and this response may not provide the immediate support she needs.

B) Calling for transportation to the hospital is the best response. This action demonstrates immediate support and concern for her well-being and allows her to prioritize reaching her child. It provides practical assistance in a moment of crisis and helps ensure she can get to her child as quickly as possible.

C) Asking how serious the collision was may seem relevant, but it could increase anxiety for the employee. She may not have this information, and discussing the severity of the situation could lead to further distress when she is already overwhelmed.

D) Asking what she thinks she should do could also add pressure to make a decision at a time when she is likely feeling helpless and confused. In a crisis, offering direct support and assistance is typically more effective than seeking input from the individual.

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

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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