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 B
Explanation
A. Allow the client to pace alone until physically tired: While pacing can be a coping mechanism, leaving the client alone may not be the most therapeutic approach. It is important for the nurse to provide support and assess the client's emotional state.
B. Walk with the client at a gradually slower pace: This is the correct answer. Walking with the client at a gradually slower pace allows the nurse to offer support and engage in therapeutic communication. It provides a calming presence and can assist the client in self-regulating their anxiety.
C. Have a staff member escort the client to her room: Escorting the client to her room might be perceived as restrictive or punitive. It is generally more beneficial to engage in supportive interventions and encourage coping strategies.
D. Instruct the client to sit down and stop pacing: Giving direct orders to stop pacing may increase anxiety and may not be an effective approach. It is often better to engage in a supportive manner and explore ways to help the client manage their anxiety.
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.
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