Which of the options below would be a priority nursing diagnosis?
Anxiety
Ineffective coping
Chronic low self-esteem
Self-harm
The Correct Answer is D
Choice A Reason:
Anxiety is incorrect. While anxiety is a valid concern, it may not be an immediate threat to the individual's safety.
Choice B Reason:
Ineffective coping is incorrect. This is relevant, but it doesn't address the urgency associated with potential self-harm.
Choice C Reason:
Chronic low self-esteem is incorrect. Low self-esteem is a significant issue, but it may not require immediate intervention compared to the risk of self-harm.
Choice D Reason:
Self-harm is correct. Assessing and addressing the risk of self-harm takes precedence, as it involves ensuring the immediate safety and well-being of the individual. Once the risk of self-harm is addressed, the nurse can then explore and address other related concerns, such as anxiety, coping mechanisms, and self-esteem.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Engaging in friendly interactions with the client is correct. Developing a therapeutic relationship involves creating a supportive and empathetic connection with the client. Engaging in friendly interactions helps build trust and rapport. This approach fosters a positive environment for communication and collaboration.
Choice B Reason:
Instructing the client on how he should behave is incorrect. Instructing the client on how to behave can be perceived as directive and may hinder the development of a collaborative and trusting relationship.
Choice C Reason:
Setting limits for the relationship is incorrect. While setting boundaries is important, using the term "limits" can convey a sense of restriction. It's crucial to establish appropriate boundaries, but the term "limits" may not promote the openness needed in a therapeutic relationship.
Choice D Reason:
Promoting the use of transference by the client is incorrect. Promoting transference involves encouraging the client to project feelings from past relationships onto the nurse. This is generally not considered a therapeutic approach and may lead to misunderstandings in the therapeutic relationship.
Correct Answer is B
Explanation
Choice A Reason:
This response is dismissive and invalidates the son's feelings of guilt. It does not acknowledge or address his emotional distress. Providing false reassurance and shifting focus to work is not therapeutic.
Choice B Reason:
This response reflects therapeutic communication. It validates the son’s feelings by acknowledging his guilt and encourages him to express his emotions. Reflective listening allows the nurse to build trust and support the son in processing his emotions.
Choice C Reason:
Asking "Why" can feel accusatory or judgmental, making the son defensive. While the statement attempts to provide reassurance, it fails to address his emotional state and may shut down further communication.
Choice D Reason:
Although this response provides some reassurance and normalization, it minimizes the son's emotions by focusing on generalizations. It lacks the reflective quality necessary for therapeutic communication in this situation.
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