A newly admitted patient is severely depressed, lost 20 pounds over the past month, and expresses hopelessness for the future. Select the priority nursing diagnosis

Risk for suicide

Risk for injury

Powerlessness

Risk for imbalance nutrition

Answer and Explanation

The Correct Answer is A

A. Priority. The patient is exhibiting severe depression, weight loss, and expressing hopelessness, which are all indicators of an increased risk for suicide. Assessing and addressing the risk for suicide is crucial to ensuring the safety and well-being of the patient.

B. Incorrect. While the patient may be at risk for injury due to factors such as poor nutrition and potential self-harm, the immediate concern in this case is the risk for suicide, given the patient's severe depression and expressed hopelessness.

C. Incorrect. Powerlessness may be a relevant nursing diagnosis for individuals experiencing depression, but the immediate concern in this case is the risk for suicide. Addressing the patient's sense of powerlessness can be part of the broader care plan, but it's not the priority.

D. Incorrect. While the patient has experienced significant weight loss, the priority at this time is addressing the risk for suicide. Once the immediate safety concern is addressed, nutritional concerns can be addressed as part of the overall care plan.

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Correct Answer is A

Explanation

A. "I'm the world's most perceptive attorney.": This statement reflects grandiosity, a common feature of grandiose delusions. The client is expressing an exaggerated belief in their own importance and abilities, indicating a distorted perception of reality.

B. "The FBI is out to get me": This statement suggests paranoid delusions, where the client believes they are being persecuted or conspired against. It does not specifically indicate grandiose delusions.

C. "I can't stop my sexual urges. They have led me to numerous affairs": This statement reflects impulsivity and hypersexuality, which are common features in manic episodes but do not specifically indicate grandiose delusions.

D. "My wife is distraught about my overspending": This statement reflects a consequence of manic behavior (overspending) but does not directly indicate grandiose delusions.

A. Maintain consistency of care by open communication to avoid staff manipulation B. Maintain unit order by the application of autocratic leadership C. Allow the clients to apply the democratic process when developing unit rules D. Allow the client spokesperson to verbalize concerns during a unit staff meeting

Correct Answer is A

Explanation

A. Maintain consistency of care by open communication to avoid staff manipulation: This is the correct answer. Borderline personality disorder (BPD) clients may engage in splitting behaviors, which involve polarized views of staff as either all good or all bad. Maintaining consistency of care and open communication can help prevent manipulation and ensure fair and transparent interactions.

B. Maintain unit order by the application of autocratic leadership: Autocratic leadership, characterized by a top-down approach with limited input from others, may not be the most effective strategy in this situation. It may lead to resistance from clients and potentially escalate the conflict.

C. Allow the clients to apply the democratic process when developing unit rules: While democratic processes are generally beneficial, allowing clients to unreasonably demand modifications of unit rules without considering the overall impact on the therapeutic environment may not be appropriate. It's important to balance client involvement with maintaining a structured and therapeutic milieu.

D. Allow the client spokesperson to verbalize concerns during a unit staff meeting: While it's important to provide a platform for clients to express concerns, allowing a spokesperson to verbalize concerns during a staff meeting should be done in a manner that maintains order and follows the therapeutic goals of the unit. It should not involve unreasonably demanding modifications without a careful consideration of the impact on the overall treatment milieu.

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A newly admitted patient is severely depressed, lost 20 pounds over the past month, and expresses hopelessness for the future. Select the priority nursing diagnosis

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize which client statement would provide supportive evidence of this symptom?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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