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 B
Explanation
A. Building a trusting relationship:Establishing trust is essential in therapeutic relationships, especially with clients at risk for self-harm. However, ensuring the client’s immediate safety by searching belongings takes precedence to protect the client from further harm.
B. Searching her belongings:This is the first priority to ensure Patty’s immediate safety and prevent access to any objects she could use to harm herself. This action addresses the immediate risk and creates a safer environment for her.
C. Orienting her to the unit. Orientation to the unit helps the client feel more comfortable and understand the rules and layout of the facility, but it is not as urgent as ensuring her safety upon admission.
D. Helping her settle into her room:Assisting Patty in getting comfortable is important for her overall well-being but is secondary to securing her environment by removing any potentially harmful items.
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.
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