A client with depression is admitted to the hospital following a suicide attempt. Which nursing diagnosis would be most appropriate at this time?
Disturbed body image related to depression
Imbalanced nutrition: Less than body requirements related to depression
Hygiene self-care deficit related to depression
Risk for self-directed violence related to depression
The Correct Answer is D
A. Disturbed body image related to depression: While body image disturbances can occur with depression, it is not the primary concern following a suicide attempt.
B. Imbalanced nutrition: Less than body requirements related to depression: While nutritional imbalances may be present in clients with depression, the most pressing concern after a suicide attempt is safety.
C. Hygiene self-care deficit related to depression: A self-care deficit is often present in depression but is not the most urgent diagnosis after a suicide attempt.
D. Risk for self-directed violence related to depression: This is the most appropriate nursing diagnosis following a suicide attempt, as it directly addresses the client’s risk of harm to themselves.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Agranulocytosis: Carbamazepine carries a boxed warning for serious hematologic effects, including agranulocytosis and aplastic anemia. Agranulocytosis is a significant drop in white blood cell count, leading to a high risk of infection.
B. Birth defects: While carbamazepine is associated with birth defects when taken during pregnancy, the boxed warning specifically highlights the risk of severe blood disorders like agranulocytosis.
C. Skin rash: Carbamazepine can cause serious skin reactions, including Stevens-Johnson syndrome and toxic epidermal necrolysis, but the boxed warning focuses more on the hematologic risks.
D. Liver damage: Although carbamazepine can cause liver damage, this is not the primary focus of the boxed warning, which emphasizes hematologic effects.
Correct Answer is D
Explanation
A. Place the client on his back, remove dangerous objects, and insert a bite block. Placing a client on their back during a seizure increases the risk of airway obstruction, and inserting a bite block is not recommended as it can cause injury.
B. Place the client on his side, remove dangerous objects, and insert a bite block. While positioning the client on their side is correct, inserting a bite block is contraindicated due to the risk of injury to the client.
C. Place the client on his back, remove dangerous objects, and hold down his arms. Restraining a client during a seizure is not recommended as it can cause injury. Placing the client on their back also poses a risk of airway obstruction.
D. Place the client on his side, remove dangerous objects, and protect his head. Positioning the client on their side helps maintain airway patency, removing dangerous objects prevents injury, and protecting the head helps prevent head trauma during the seizure.
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