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 B

Explanation

A. "Group therapy is an economical way of providing therapy to many clients concurrently.": While this statement may be true, it does not directly address the client's concerns or provide information about the voluntary nature of group participation.

B. "Group therapy is optional. You can go if you find the topic helpful and interesting.": This is the correct answer. Acknowledging the client's autonomy and providing information about the voluntary aspect of group therapy respects the client's preferences and promotes a collaborative therapeutic relationship.

C. "Group therapy is mandatory. All clients must attend.": This statement is more authoritarian and does not take into account the individual needs and preferences of the client. It is important to involve clients in decisions about their treatment whenever possible.

D. "The purpose of group therapy is to learn and practice new coping skills.": While this statement provides information about the purpose of group therapy, it does not directly address the client's question about the optional nature of attendance.

A. Why do you think you are being lied about and poisoned?" B. You are mistaken. Nobody is lying about you or trying to poison you." C. Who is lying about you and trying to poison you?" D. You seem to be having very frightening thoughts."

Correct Answer is D

Explanation

A. "Why do you think you are being lied about and poisoned?": This question may come across as confrontational or challenging, potentially increasing the client's anxiety or defensiveness. It's important to acknowledge the client's feelings rather than questioning their beliefs directly.

B. "You are mistaken. Nobody is lying about you or trying to poison you.": This statement is dismissive and may cause the client to feel invalidated. It is crucial to acknowledge the client's feelings and experiences, even if they are not based on reality.

C. "Who is lying about you and trying to poison you?": This question may unintentionally reinforce the delusional thinking by suggesting that someone is indeed lying or trying to poison the client. It's essential to avoid validating or encouraging the delusional content.

D. "You seem to be having very frightening thoughts.": This statement acknowledges the client's emotions without directly challenging the delusional content. It shows empathy and creates an open and non-confrontational environment, allowing the client to express their feelings and experiences.

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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 newly admitted client asks. "Why do we need a unit schedule? I'm not going to these groups. I'm here to get some rest." Which is the most appropriate nursing response?

Correct Answer is B

Explanation

A nurse is caring for a client who has schizophrenia and tells the nurse. "They lie about me all the time and they are trying to poison my food." Which of the following statements should the nurse make?

Correct Answer is D

Explanation

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