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Which of the options below would be a priority nursing diagnosis?

Anxiety

Ineffective coping

Chronic low self-esteem

Self-harm

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A Reason:

Facing reality and developing standards for responsible behavior is inappropriate. This goal aligns more with reality therapy or choice theory, which focuses on helping individuals take responsibility for their behavior and make choices that lead to responsible actions.

Choice B Reason:

Examining irrational beliefs and eliminating self-defeating behaviors is appropriate. Beck's cognitive-behavioral therapy (CBT) is based on the premise that thoughts influence feelings and behaviors. The goal of CBT is to identify and change irrational or distorted thoughts that contribute to negative emotions and behaviors. This process involves examining irrational beliefs and challenging cognitive distortions to promote more realistic and adaptive thinking.

Choice C Reason:

Developing satisfactory relationships, maturity, and relative freedom from anxiety is inappropriate. This goal may align with psychodynamic or humanistic approaches that emphasize personal growth, self-awareness, and improvement in relationships.

Choice D Reason:

Reducing body tension through biofeedback training is inappropriate. This goal is more aligned with behavioral approaches that use techniques like biofeedback to address physiological symptoms.

A. "Your mother will be fine, you shouldn't work so much." B. “So, it seems that you feel responsible for what happened to your mother” C. "Why do you blame yourself? You could not have prevented the stroke” D. “You are not responsible for your mothers’ stroke but many people in your situation feel this way”

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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Which of the options below would be a priority nursing diagnosis?

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Naxlex Comprehensive Predictor Exams

Which goal represents Beck's cognitive-behavioral model?

Correct Answer is B

Explanation

A nurse is caring for an older adult client who had a cerebrovascular accident and has right-sided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist that his mother live with him. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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A nurse is caring for a group of clients on a mental health unit. Which of the following actions should the nurse implement to establish therapeutic relationships with the clients?