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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Favoring clients over others based upon their mental health diagnosis is not an indication of bias: This statement is incorrect. Favoring or discriminating against clients based on their mental health diagnosis is a clear indication of bias, and it is an issue that the nursing profession aims to address.
B. Displaying basis & conscious art: It seems like there might be a typo in this option. Assuming it means "Displaying bias, conscious or not," this could be a relevant point in discussing unconscious biases that individuals may hold, impacting their interactions with clients.
C. There is a negative stigmatization for mental lives: This is the correct answer. This statement acknowledges the existence of negative stigmatization associated with mental health. Addressing and reducing mental health stigma is an essential aspect of providing quality mental health care.
D. Bias is often isolated to inpatient hospitalization: This statement is not accurate. Bias can manifest in various healthcare settings, not just inpatient hospitalization. It is important to address bias across all levels of care to ensure equitable and unbiased treatment for individuals with mental health concerns.
Correct Answer is A
Explanation
A. "I understand that you are angry, but this behavior will not be tolerated": This response sets a clear boundary regarding unacceptable behavior while acknowledging the client's emotional state. It communicates to the client that their actions are not acceptable, but it does so in a firm yet empathetic manner. This statement also maintains professionalism and ensures a safe and respectful environment for both the client and the nurse.
B. "You are very disrespectful. You need to learn to control yourself": This statement is confrontational and may escalate the client's anger or resistance. It focuses on blaming the client rather than exploring potential modifications to improve the situation.
C. "What behaviors could you modify to improve this situation?":may not be as effective in this context because it places the responsibility solely on the client to modify their behavior without directly addressing the inappropriate actions exhibited. Additionally, individuals with antisocial personality disorder may have difficulty recognizing the impact of their behavior on others or may be resistant to changing their actions without external intervention or consequences.
D. "What anti-personality disorder medications have helped you in the past?": Antisocial personality disorder is not typically treated with specific medications, and individuals with this disorder may not seek or comply with medication interventions. Asking about medications may not be relevant or helpful in addressing the immediate behavioral issues.
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