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:
"People in the mental health category of the continuum do not experience stress." This statement indicates a misunderstanding about the mental health continuum. Mental health does not imply the absence of stress; rather, it is about one's overall psychological well-being. Even individuals with good mental health may experience stress at times. The mental health continuum recognizes that people can move along different points, experiencing fluctuations in mental health based on various factors.
Choice B Reason:
“People can shift along various points of the mental health continuum. “This statement acknowledges the dynamic nature of mental health, indicating that individuals can move between different points on the continuum based on their mental well-being.
Choice C Reason:
"Most people are on some point of the mental health continuum. “This statement recognizes that mental health is a spectrum, and most individuals fall somewhere along this continuum.
Choice D Reason:
"Mental health is an important point of the mental heat continuum. “This statement reinforces the significance of mental health as a key aspect of overall well-being, which aligns with the concept of the mental health continuum.
Correct Answer is D
Explanation
Choice A Reason:
Differentiation is incorrect. Differentiation refers to the ability of family members to maintain their individuality while remaining emotionally connected. It is not directly related to involving a third person in conflicts.
Choice B Reason:
Scapegoating is incorrect. Scapegoating involves blaming one family member for the family's problems. While this can be a dysfunctional family dynamic, it is not specifically about involving a third person in conflicts.
Choice C Reason:
Double Binding is incorrect. Double binding involves conflicting messages that create a no-win situation for the recipient. It does not specifically involve the inclusion of a third person in conflicts as observed in the given scenario.
Choice D Reason:
Triangulation is correct. Triangulation in family systems therapy occurs when a third person, often a child, is involved in the conflicts between two other family members. In this scenario, Kate is venting her frustrations to her younger son, which creates a triangle or three-person dynamic in the family system. Triangulation can serve as a way for family members to stabilize their relationships by shifting the focus or tension onto a third party.
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