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. Incorrect. Falling asleep in the chair and refusing to eat lunch is not indicative of tardive dyskinesia (TD). TD is characterized by involuntary movements, not by changes in sleep patterns or appetite.
B. Correct. Grimacing and lip smacking are characteristic movements associated with tardive dyskinesia. TD is a side effect of long-term use of typical antipsychotic medications, and it involves involuntary, repetitive movements, often involving the face and mouth.
C. Incorrect. Excessive salivation and drooling are not specific to tardive dyskinesia. These symptoms may occur due to various reasons, and TD is primarily associated with abnormal, involuntary movements.
D. Incorrect. Experiencing muscle rigidity and tremors is more characteristic of other side effects or conditions, such as extrapyramidal symptoms, but it is not specific to tardive dyskinesia. TD typically involves repetitive, involuntary movements rather than tremors.
Correct Answer is A
Explanation
A. Self-destructive behavior despite alternative interventions: Mechanical restraints may be considered when a client poses an immediate risk of harm to themselves, and alternative interventions have been ineffective or are not feasible.
B. Discipline for throwing objects at staff: Mechanical restraints are not appropriate as a form of discipline. Restraints should only be used when there is an imminent risk of harm to the client or others.
C. Punishment for verbally abusing other clients: The use of restraints as a form of punishment is not ethical or appropriate. Restraints should be employed solely to prevent harm, not as a disciplinary measure.
D. Coercion to take prescribed medications: Coercion to take medications is not a valid reason for using mechanical restraints. Alternative approaches, such as therapeutic communication or discussing the need for medications with the client, should be explored.
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