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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. A client who has recently begun treatment with propranolol (Inderal) for the treatment of social phobia. Propranolol, a beta-blocker, does not have a significant risk for dependence or withdrawal symptoms. It is primarily used for physical symptoms of anxiety, such as tachycardia.

B. A woman who has been taking lorazepam (Ativan) for several months after witnessing a traumatic motor vehicle accident. Lorazepam is a benzodiazepine, which has a high potential for dependence and withdrawal, especially with long-term use. This client is the most at risk for these issues.

C. A man whose obsessive-compulsive disorder (OCD) is being treated long-term with paroxetine (Paxil). While discontinuation symptoms can occur with SSRIs like paroxetine, the risk of dependence is significantly lower than with benzodiazepines.

D. A client with generalized anxiety disorder who has responded well since beginning treatment with fluoxetine (Prozac) earlier in the year. Like paroxetine, fluoxetine is an SSRI, and while discontinuation symptoms may occur, the risk of dependence is low.

A. Demonstrate empathy for the client by trying to mimic the client's state of anxiety. B. Tell the client that you must leave to go report his symptoms to the psychiatrist on duty. C. Tell the client this is an acute exacerbation with a positive prognosis and low morbidity. D. Stay with the client, emphasizing that he is safe and that you will remain with him.

Correct Answer is D

Explanation

A. Demonstrate empathy for the client by trying to mimic the client's state of anxiety. This is not appropriate as it could exacerbate the client’s anxiety rather than alleviate it. The nurse should remain calm and provide reassurance.

B. Tell the client that you must leave to go report his symptoms to the psychiatrist on duty. Leaving the client alone during a panic attack could increase their feelings of fear and isolation, worsening the situation.

C. Tell the client this is an acute exacerbation with a positive prognosis and low morbidity. While this information is correct, it does not directly address the client's immediate need for reassurance and safety during the panic attack.

D. Stay with the client, emphasizing that he is safe and that you will remain with him. This is the most appropriate intervention as it provides the client with a sense of safety and security, which is crucial during a panic attack.

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A client with depression is admitted to the hospital following a suicide attempt. Which nursing diagnosis would be most appropriate at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following clients is most likely to be at risk for drug dependence and difficulties with withdrawal?

Correct Answer is B

Explanation

The nurse is caring for a client who is being treated in the emergency department for a panic attack. Which of the following nursing interventions would be most appropriate?

Correct Answer is D

Explanation

The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?

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