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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Axons: Axons are nerve cell processes that transmit signals away from the cell body. While axons are essential for communication between nerve cells, their structure or function is not directly implicated in the altered behavior associated with schizophrenia.
B. Neurotransmitters: This is the correct answer. In schizophrenia, there is evidence of dysregulation in neurotransmitter systems, particularly dopamine. Dopamine dysregulation is associated with both positive and negative symptoms of schizophrenia. In the case of negative symptoms, such as social withdrawal and reduced emotional expression, hypoactivity in dopamine pathways may play a role.
C. Dendrites: Dendrites are nerve cell processes that receive signals from other neurons. Similar to axons, dendrites are crucial for communication between nerve cells, but their structure or function is not specifically implicated in the altered behavior associated with schizophrenia.
D. Synapses: Synapses are the junctions between nerve cells where neurotransmitters are released to transmit signals. While synapses play a critical role in neurotransmission, the altered behavior in schizophrenia is more closely linked to the dysregulation of neurotransmitters, particularly dopamine, than to structural changes in synapses.
Correct Answer is A
Explanation
A. "I can see that you are angry. Let's discuss ways to approach Peter with your concerns."
This response is empathetic and invites the client to discuss their concerns. However, it doesn't explicitly address the client's request for the nurse to take action. The more appropriate approach would involve the nurse taking direct responsibility for addressing the issue.
B. "Why are you overreacting to the issue?"
This response may be perceived as dismissive and judgmental. It does not validate the client's concerns or address the issue constructively.
C. "You should bring this to the attention of your treatment team."
While involving the treatment team is important, the client has directly approached the nurse with a concern. It is appropriate for the nurse to take the initial step in addressing the issue directly rather than immediately redirecting the client to the treatment team.
D. "I'll talk to Peter and present your concerns."
This is the most appropriate response. It acknowledges the client's concerns, takes responsibility for addressing the issue, and ensures that the client's voice is heard. The nurse can discuss the matter with Peter and work towards a resolution.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.