When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?
Ineffective breathing pattern.
Risk for injury.
Ineffective coping.
Impaired comfort.
The Correct Answer is A
Choice A rationale: Ineffective breathing pattern is the highest priority nursing problem. Aspiration of a caustic material can lead to respiratory compromise, and ensuring adequate oxygenation takes precedence.
Choice B rationale: Risk for injury is important, but respiratory concerns associated with aspiration take priority in this situation.
Choice C rationale: Ineffective coping is relevant but does not take precedence over addressing immediate physiological needs such as breathing.
Choice D rationale: Impaired comfort is important, but the priority is to ensure the client's respiratory status and address potential complications of caustic material aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Reports difficulties with short-term memory since a traumatic brain injury is not an indication for using the CAGE questionnaire. The CAGE questionnaire is specifically designed to screen for alcohol use disorder.
Choice B rationale: Medical history, including recent sexual assault, does not directly correlate with the need for the CAGE questionnaire. The CAGE questionnaire focuses on identifying problematic alcohol use.
Choice C rationale: Describing self as a social drinker who drinks alcoholic beverages daily is an indication for using the CAGE questionnaire. The client's daily consumption and identification as a social drinker raise concerns about potential alcohol misuse or dependency.
Choice D rationale: Client's medication history, including the frequent use of antidepressants, is not an indication for using the CAGE questionnaire. The CAGE questionnaire is specific to alcohol use and does not address antidepressant use.
Correct Answer is B
Explanation
Choice A rationale: Monitoring for binging activities is important, but addressing the potential physiological complications of bulimia, such as electrolyte imbalances, takes precedence.
Choice B rationale: Assessing and reporting the client's electrolyte status is the highest priority as bulimia nervosa can lead to severe electrolyte imbalances, which may result in life-threatening complications.
Choice C rationale: Assigning care based on age is not a priority in addressing the immediate health risks associated with bulimia nervosa.
Choice D rationale: While group therapy is beneficial, addressing the client's physical health and safety is the highest priority.
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