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 ["3.5"]
Explanation
He has been prescribed Fluphenazine decanoate 87.5 mg intramuscularly every 3 weeks to treat his schizophrenia. The nurse checks the medication order and the vial label. The vial contains Fluphenazine decanoate 25 mg per milliliter. To calculate the amount of medication to administer, the nurse uses the formula:
dose ordered / dose available = mL to administer
Substituting the values, the nurse gets:
87.5 mg / 25 mg/ml = 3.5 ml
Therefore, the nurse will administer 3.5 milliliters of Fluphenazine decanoate for this dose.
Correct Answer is B
Explanation
Choice A Reason:
Making an evaluation about the patient's problem is incorrect. Making an evaluation may involve the nurse imposing their judgment on the patient's situation, which can hinder effective communication.
Choice B Reason:
Restating the main feelings or thoughts the patient has expressed is correct. Restating the main feelings or thoughts the patient has expressed is a therapeutic communication technique known as paraphrasing. This technique demonstrates active listening and shows the patient that the nurse is paying attention to their concerns. It allows the nurse to reflect back to the patient what has been said, confirming understanding and encouraging further communication.
Choice C Reason:
Saying "I understand what you're saying" is incorrect. While expressing understanding is important, simply stating "I understand" might be perceived as superficial if not accompanied by concrete examples or restatement of the patient's expressed thoughts and feelings.
Choice D Reason:
Offering a leading question such as "And then what happened?", is incorrect. Asking a leading question can be perceived as directive and may steer the conversation in a particular direction. It might not convey the same level of active listening as restating the patient's own words and feelings.
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