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 D
Explanation
A. Provide client with high-calorie finger foods throughout the day:
While providing high-calorie finger foods may increase caloric intake, it may not be the most effective strategy for a specific weight gain goal. It's essential to encourage a balanced and varied diet.
B. Teach the importance of a varied diet to meet nutritional needs:
This is a good general approach to promote overall nutritional health, but it may not be specific enough to address the immediate goal of gaining 2 pounds within a week.
C. Initiate total parenteral nutrition to meet dietary needs:
Total parenteral nutrition is an invasive and aggressive intervention typically reserved for cases where oral or enteral feeding is not possible or insufficient. It is not the first-line approach for someone who can consume food orally.
D. Accompany client to cafeteria to encourage adequate dietary consumption:
This is the most appropriate intervention. Accompanying the client to the cafeteria provides an opportunity for direct encouragement and support during meals. It helps ensure that the client is consuming an adequate amount of food, which is crucial for the goal of gaining 2 pounds within a week.
Correct Answer is B
Explanation
A. Researchers have been unable to demonstrate a link between nature (biology and genetics) and nurture (environment): This statement is inaccurate. There is substantial evidence supporting the interaction between nature (biology and genetics) and nurture (environment) in the development of mental health conditions, including depression.
B. Medications are one way to address chemical imbalances. Environmental and interpersonal factors can also have an impact on biological factors: This is the correct answer. It acknowledges the role of medications in addressing chemical imbalances but also emphasizes the importance of environmental and interpersonal factors in influencing biological factors. This response aligns with a biopsychosocial model of understanding mental health.
C. Because biological factors are the sole cause of depression, medications will improve your mood: This statement oversimplifies the complex etiology of depression. Depression is a multifactorial condition influenced by biological, psychological, and environmental factors. Medications may be part of the treatment, but they are not the sole solution.
D. Environmental factors have been shown to exert the most influence in the development of depression: This statement is also incorrect. Depression is influenced by a combination of biological, psychological, and environmental factors. No single factor is solely responsible for the development of depression.
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