A client who recently 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.

Answer and Explanation

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 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.

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Correct Answer is D

Explanation

An 80-year-old patient with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis is at the highest risk for developing delirium. Multiple factors such as advanced age, severe illness, and multiple comorbidities increase the risk of delirium.

A. Foster a social relationship. B. Focus on the attitude of the client. C. Focus on the client and to build a rapport. D. Focus on the staff member and to build rapport.

Correct Answer is C

Explanation

Choice A rationale
While fostering a social relationship can be a part of therapeutic communication, it is not the primary goal. The main focus is on the client’s needs and concerns.
Choice B rationale
Focusing on the attitude of the client is not the primary goal of therapeutic communication. The main goal is to understand the client’s experiences and feelings.
Choice C rationale
The primary goals of therapeutic communication are to focus on the client and to build a rapport. This involves understanding the client’s needs, concerns, and emotions effectively.
Choice D rationale
Focusing on the staff member and building rapport is not the primary goal of therapeutic communication. The main focus should be on the client.

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A client who recently 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In a medical-surgical unit, the nurse is monitoring several patients. Which patient does the nurse identify as being at the highest risk for developing delirium?

Correct Answer is D

Explanation

What are the goals of therapeutic communication?

Correct Answer is C

Explanation

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A client who recently 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?