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 D
Explanation
Choice A Reason:
Formulating a nursing diagnosis is incorrect. This occurs after a comprehensive assessment of the patient's needs, and it helps guide the planning and implementation of nursing care.
Choice B Reason:
Planning for continued care is incorrect. Once the nursing diagnosis is formulated, the nurse can develop a plan of care, including interventions and goals for the patient.
Choice C Reason:
Promoting patient's insight is incorrect. This is a part of the ongoing therapeutic process and involves helping the patient gain self-awareness and understanding of their thoughts, feelings, and behaviors. It typically occurs after the initial assessment and planning.
Choice D Reason:
Examining personal biases is correct. In the nurse-patient relationship, examining personal biases is a foundational and essential step that should happen first. It involves the nurse being self-aware and acknowledging any personal biases or prejudices that might affect the therapeutic relationship. Recognizing and addressing personal biases is crucial for providing unbiased and patient-centered care.
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.
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