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 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.

A. "I can see that you're uncomfortable now, so we can wait until tomorrow." B. "If you refuse these pills, you'll have to get an injection C. "What is it about the medicine that you don't like?" D. "You know you have to take this medicine for your own good."

Correct Answer is C

Explanation

A. "I can see that you're uncomfortable now, so we can wait until tomorrow." Delaying the medication could worsen the client's condition and does not address the underlying reason for the refusal.

B. "If you refuse these pills, you'll have to get an injection." This response is coercive and could damage trust between the client and the nurse. It does not explore the client's concerns.

C. "What is it about the medicine that you don't like?" This response is therapeutic as it opens a dialogue with the client to understand their concerns, which can help in addressing the reluctance and promoting adherence to the medication.

D. "You know you have to take this medicine for your own good." This response is paternalistic and dismisses the client's autonomy and concerns, which may lead to further resistance.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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