A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is voluntarily admitted to the psychiatric unit.
Which of the following nursing diagnoses has the highest priority?
Ineffective coping related to inadequate stress management.
Hopelessness related to recent divorce.
Spiritual distress related to conflicting thoughts about suicide and sin.
Risk for suicide related to highly lethal plan.
The Correct Answer is D
Choice A rationale
While ineffective coping related to inadequate stress management is a valid nursing diagnosis, it is not the highest priority in this situation. The client’s life is not immediately at risk due to ineffective coping.
Choice B rationale
Hopelessness related to recent divorce is a significant concern, but it is not the highest priority. The immediate threat to the client’s life is the suicidal ideation with a highly lethal plan.
Choice C rationale
Spiritual distress related to conflicting thoughts about suicide and sin is a potential nursing diagnosis for this client. However, the immediate life-threatening issue takes precedence.
Choice D rationale
Risk for suicide related to highly lethal plan is the highest priority nursing diagnosis. The client has a plan to commit suicide with a handgun, which is a highly lethal method. Immediate intervention is required to ensure the client’s safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale
Encouraging the client to take naps during the day to make up for lost sleep can interfere with normal sleep patterns. Therefore, this is not a recommended intervention.
Choice B rationale
Having the client engage in strenuous physical exercise just before bedtime can increase brain metabolic activity and wakefulness. Hence, this is not a suitable intervention.
Choice C rationale
Arranging for the client to receive at least 20 minutes of natural sunlight each day can improve sleep patterns. This is a recommended intervention.
Choice D rationale
Serving the client a glass of warm milk in the evening can promote comfort and relaxation to aid sleepiness. This is a recommended intervention.
Choice E rationale
Suggesting that the client take a warm bath before going to bed can be a part of a relaxing activity before bedtime. This is a recommended intervention.
Correct Answer is D
Explanation
Choice A rationale
While ineffective coping related to inadequate stress management is a valid nursing diagnosis, it is not the highest priority in this scenario. The client’s threat to commit suicide with a handgun indicates a clear and immediate risk.
Choice B rationale
Hopelessness related to recent divorce is a significant concern and may contribute to the client’s suicidal ideation. However, the immediate threat of suicide takes precedence.
Choice C rationale
Spiritual distress related to conflicting thoughts about suicide and sin may be a factor in the client’s mental state, but it is not the immediate concern. The client’s life is in danger, which must be addressed first.
Choice D rationale
Risk for suicide related to a highly lethal plan is the highest priority nursing diagnosis. The client has a clear plan (using a handgun) and means (access to a handgun), indicating a high risk for suicide.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.