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:
Demonstrate genuineness when communicating is correct. Establishing therapeutic relationships in mental health nursing involves demonstrating genuineness, empathy, and trustworthiness in communication. Genuineness involves being authentic, sincere, and honest in interactions with clients. It fosters a sense of trust and connection, which is essential for the therapeutic relationship.
Choice B Reason:
Focusing on the words of the clients is incorrect. While it's important to listen actively to clients, effective communication goes beyond just focusing on words. Nonverbal cues, emotions, and the overall context of communication are also crucial.
Choice C Reason:
Providing sympathy during interactions is incorrect. Sympathy involves feeling sorry for someone, which may not always be helpful in a therapeutic relationship. Empathy, where the nurse understands and shares the client's feelings, is generally more therapeutic.
Choice D Reason:
Controlling the pace of establishing the nurse-client relationships is incorrect. The establishment of therapeutic relationships is a collaborative process, and attempting to control the pace might hinder the development of trust. It's important to be responsive to the client's needs and preferences.
Correct Answer is D
Explanation
Choice A Reason:
"I’m so sad and I feel I haven't accomplished much in my life." This statement may relate more to feelings of despair and a sense of unfulfilled purpose, which could be associated with Erikson's stage of Integrity vs. Despair (late adulthood).
Choice B Reason:
"I’m so anxious, can't seem to trust anyone. “This statement may indicate difficulties with trust and may be more aligned with Erikson's stage of Trust vs. Mistrust (infancy).
Choice C Reason:
"I'm so tired after work that I just want to watch TV and be alone. “This statement may reflect fatigue or a desire for solitude and may not directly represent the identity development struggles associated with Erikson's Identity vs. Role Confusion stage.
Choice D Reason:
"I'm so confused about what my goals are.” Erikson's phase of Identity vs. Role Confusion occurs during adolescence, and individuals in this stage are exploring and forming their own identity. The statement "I'm so confused about what my goals are" suggests a struggle with establishing a clear sense of identity and future direction, which is characteristic of the challenges faced during this developmental stage.
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