A client arrives on the psychiatric unit exhibiting restlessness, disorientation, incoherent speech, agitation, purposeless physical activity, and suicidal ideations. Which is the priority nursing diagnosis for this client?
Hopelessness
Disturbed identity
Risk for self-harm
Ineffective individual coping
The Correct Answer is C
Choice A reason: Hopelessness is a valid and clinically significant NANDA-I nursing diagnosis relevant to clients with psychiatric disorders, particularly in the context of depression and suicidality. It is defined as a subjective state in which an individual sees limited or no alternatives or personal choices available and is unable to mobilize energy on their own behalf. While hopelessness is an important contributing factor to suicidal ideation and may be addressed in the nursing care plan, it is not the priority nursing diagnosis in this clinical scenario. Per nursing care prioritization principles, actual or potential physical safety concerns supersede psychological or psychosocial nursing diagnoses.
Choice B reason: Disturbed personal identity is a nursing diagnosis pertaining to the inability to distinguish between self and nonself and is most applicable to conditions involving identity confusion such as dissociative identity disorder, schizophrenia, or severe psychotic states. While the client presents with disorientation and incoherent speech that may suggest an altered mental state, these symptoms in combination with expressed suicidal ideations make the risk of immediate physical harm the overriding clinical concern. The presence of suicidal ideations requires prioritization of safety above all other nursing diagnoses, consistent with established nursing care hierarchy principles.
Choice C reason: Risk for self-harm is the priority nursing diagnosis in this clinical scenario due to the client's expressed suicidal ideations combined with acute agitation, disorientation, and purposeless physical activity, all of which indicate a severe and complex psychiatric presentation with immediate physical safety implications. The NANDA-I nursing diagnosis of risk for self-directed violence encompasses the threat posed by suicidal ideation and intent. In accordance with the nursing priority framework aligned with Maslow's hierarchy and psychiatric emergency management standards, the prevention of physical harm to the client is the foremost nursing obligation and must guide all immediate care decisions.
Choice D reason: Ineffective individual coping is a nursing diagnosis describing the inability to form a valid appraisal of stressors, inadequate choices of practiced responses, and inability to use available resources to manage demands. While it is relevant to the long-term management of psychiatric disorders and may be included in the broader nursing care plan, it represents a psychosocial diagnosis that is lower in priority than the immediate physical safety risk presented by suicidal ideation and agitation. Addressing coping strategies is a secondary intervention that becomes appropriate after safety has been ensured and acute crisis stabilized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Stating that depressive disorders are the 4th leading cause of years lost due to disability is factually inaccurate. According to the World Health Organization (WHO) and the Global Burden of Disease data, major depressive disorder is 1 of the leading contributors to disability worldwide and is ranked among the top causes of years lived with disability (YLD), not merely the 4th. Some data rank it as the single leading cause of disability globally when measured in YLD. Presenting it as the 4th leading cause misrepresents its global public health significance and would therefore not constitute a true statement for nursing education purposes.
Choice B reason: The monoamine hypothesis of depression, which implicates dysregulation of the neurotransmitters norepinephrine, dopamine, and serotonin in the pathophysiology of depressive disorders, is a well-established and widely accepted neuroscientific framework. Evidence supporting this hypothesis comes from multiple sources, including the clinical efficacy of pharmacological agents that enhance monoaminergic neurotransmission, such as SSRIs, SNRIs, MAOIs, and tricyclic antidepressants, as well as neurobiological research demonstrating altered monoamine receptor density and function in individuals with depression. While the monoamine hypothesis has been refined and expanded to include neuroendocrine, neuroplasticity, and inflammatory mechanisms, the fundamental role of these 3 neurotransmitters remains an established and clinically relevant true statement.
Choice C reason: The assertion that depression in older adults is easier to diagnose is factually incorrect. Depression in geriatric populations is notoriously difficult to diagnose for multiple reasons: older adults often present with atypical symptoms such as somatic complaints, cognitive impairment (depressive pseudodementia), anhedonia rather than overt sadness, and medical comorbidities that mask or mimic depressive features. Additionally, both patients and providers may attribute depressive symptoms to normal aging. Depression in older adults is frequently underdiagnosed and undertreated due to these diagnostic challenges, making this statement demonstrably false and clinically misleading.
Choice D reason: The assertion that depressive disorders are more prevalent in males than females contradicts robust epidemiological evidence. Consistently across cross-cultural, national, and international studies, major depressive disorder and dysthymic disorder are approximately 2 times more prevalent in females than in males throughout the lifespan, particularly from adolescence through menopause. Hormonal factors, including estrogen and progesterone fluctuations, as well as psychosocial contributors such as higher rates of trauma exposure and socioeconomic disadvantage, are implicated in the higher female prevalence. Stating that depression is more prevalent in males is factually inaccurate and inconsistent with global epidemiological data.
Correct Answer is C
Explanation
Choice A reason: Sugar (sucrose and other dietary carbohydrates) does not interact pharmacologically with monoamine oxidase inhibitors. MAOIs exert their antidepressant effect by irreversibly inhibiting monoamine oxidase enzymes (MAO-A and MAO-B), thereby increasing the availability of monoamine neurotransmitters including serotonin, norepinephrine, and dopamine in the synaptic cleft. Dietary sugar has no role in monoamine metabolism and does not pose any clinically significant interaction risk with MAOIs. Educating a client to avoid sugar while on MAOIs would be clinically inaccurate and misleading.
Choice B reason: Calcium is an essential dietary mineral involved in bone metabolism, muscle contraction, nerve impulse transmission, and blood coagulation. It does not undergo metabolic processing via monoamine oxidase enzymes and does not interact with MAOIs in any pharmacologically relevant manner. Calcium-rich foods such as dairy products are not contraindicated during MAOI therapy. Client education regarding calcium restriction in the context of MAOI use is not supported by evidence-based pharmacological guidelines or clinical practice standards.
Choice C reason: Tyramine is a naturally occurring monoamine compound derived from the amino acid tyrosine, found in fermented, aged, and cured foods such as aged cheeses, cured meats, red wine, sauerkraut, soy sauce, and fava beans. Under normal physiological conditions, dietary tyramine is metabolized by MAO enzymes in the gastrointestinal tract and liver, preventing systemic absorption. When a client is taking an MAOI, this first-pass metabolism of tyramine is blocked, allowing large amounts of tyramine to enter systemic circulation, triggering a massive release of norepinephrine from sympathetic nerve terminals. This leads to a hypertensive crisis, manifested by severe hypertension, occipital headache, diaphoresis, tachycardia, and potentially intracranial hemorrhage, making tyramine avoidance a critical and life-saving component of patient education for MAOI therapy.
Choice D reason: Potassium is an essential electrolyte critical for maintaining cellular membrane potential, cardiac rhythm, and neuromuscular function. Like calcium, potassium does not interact with MAOIs and is not metabolized by monoamine oxidase enzymes. Foods high in potassium, such as bananas, oranges, and potatoes, are not contraindicated in clients receiving MAOI therapy. Instructing a client to avoid potassium-rich foods in the context of MAOI use reflects a fundamental misunderstanding of MAOI pharmacology.
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