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 C

Explanation

A. Emaciation: Emaciation refers to extreme weight loss and muscle wasting due to severe malnutrition, not just loss of appetite.

B. Cachexia: Cachexia is a complex syndrome associated with chronic illness, characterized by severe weight loss, muscle atrophy, and fatigue. While it may include loss of appetite, it’s not the best term for simple loss of appetite.

C. Anorexia: Anorexia is the correct medical term for loss of appetite. It can be related to various conditions, including prolonged illness.

D. Nausea: Nausea is a sensation of discomfort in the stomach with an urge to vomit, not loss of appetite.

A. hypokalemia or hyponatremia. B. acute gastrointestinal bleed. C. increased intracranial pressure. D. respiratory depression.

Correct Answer is D

Explanation

A. Hypokalemia or hyponatremia: While electrolyte imbalances are important, they are not the most immediate threat in the context of a heroin overdose.

B. Acute gastrointestinal bleed: An acute gastrointestinal bleed is not a primary concern with heroin overdose. It is not the most acute threat in this scenario.

C. Increased intracranial pressure: Increased intracranial pressure is not directly related to heroin overdose. The most pressing issue is related to the effects of the overdose.

D. Respiratory depression: Heroin overdose commonly leads to respiratory depression, which is the most immediate and life-threatening condition. Addressing respiratory depression is crucial for patient survival.

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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 C

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Paramedics have brought a patient to the emergency department with a suspected heroin overdose. The nurse should recognize that the patient's most acute threat to health at this time is:

Correct Answer is D

Explanation

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