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. These programs help clients correct distorted body image:
While behavioral programs may incorporate components related to body image, the primary focus is often on addressing and modifying specific behaviors associated with eating disorders, such as binge eating, purging, or restrictive eating.
B. These programs help clients manage uncontrollable behaviors:
This is the correct answer. Behavior modification programs aim to address and modify specific behaviors that contribute to eating disorders. This can include establishing healthier eating patterns, reducing binge-purge cycles, and promoting more adaptive coping strategies.
C. These programs allow clients to maintain control:
While the concept of control is relevant to eating disorders, behavior modification programs are designed to help clients gain control over maladaptive behaviors and establish healthier patterns. It's not about maintaining control over the disorder itself.
D. These programs address underlying client anger:
While emotions, including anger, may play a role in eating disorders, behavior modification programs are more focused on targeting and modifying specific behaviors rather than addressing underlying emotions directly. Emotional aspects may be addressed through additional therapeutic interventions
Correct Answer is A
Explanation
A. By using a screening tool such as the CAGE questionnaire: This is the correct answer. The CAGE questionnaire is a widely used tool for screening alcohol use disorders. It consists of four questions that assess whether the individual has concerns or issues related to their alcohol consumption. A positive result may indicate a need for further assessment and intervention.
B. By asking directly if the client has ever had a problem with alcohol: While direct questioning is important, using a structured screening tool provides a more standardized and objective approach. The CAGE questionnaire offers specific questions that help identify potential issues with alcohol use.
C. By holistically assessing the client using the CINA scale: The CINA scale (Checklist of Nonverbal Indicators of Affect) is primarily used to assess nonverbal behaviors related to affect. While it may be useful in certain contexts, it is not specifically designed for assessing alcohol use disorders.
D. By referring the client for physician evaluation: While physician evaluation may be necessary for a comprehensive assessment, using a screening tool such as the CAGE questionnaire is an appropriate initial step. The results of the screening tool can guide further assessment and appropriate referrals.
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