A client is admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt. Which nursing problem has the highest priority?

Impaired comfort.

Risk for injury.

Ineffective breathing pattern.

Ineffective coping.

Answer and Explanation

The Correct Answer is C

A) Impaired comfort is a relevant concern, but it is not the highest priority in the context of a potentially life-threatening situation such as aspiration of a caustic material. While comfort is important, it is secondary to immediate safety and physiological needs.

B) Risk for injury is a general concern in many situations, but in this specific case, it does not address the acute medical implications of the aspiration of caustic material. While injury could occur, the focus should be on the immediate effects of the incident.

C) Ineffective breathing pattern is the highest priority nursing problem. Aspiration of caustic material can lead to severe respiratory complications, including airway obstruction, chemical pneumonitis, and other respiratory distress. Ensuring the client has adequate ventilation and monitoring for signs of respiratory distress are critical nursing interventions that take precedence over other concerns.

D) Ineffective coping is important to address, particularly given the context of a suicide attempt; however, it is not as immediate as the potential life-threatening consequences of aspiration and ineffective breathing. The client’s physical safety must be prioritized before addressing psychological issues.

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Correct Answer is D

Explanation

A) Disrupting group activities indicates behavioral issues, but it alone does not necessarily warrant constant observation. While disruptive behavior can be concerning, it may not pose an immediate risk to the client or others.

B) Talking with nonsensical words suggests disorganized thinking or possible psychosis, which is important to note. However, this behavior does not by itself indicate that the client is in immediate danger or that they require constant observation.

C) Refusing antipsychotic medications is a significant factor, particularly in managing the client's mental health. However, refusal of medication does not automatically necessitate constant observation unless it leads to behaviors that put the client or others at risk.

D) Wandering into clients' rooms is the most concerning behavior in this context. This action can pose a risk to both the individual and other clients, potentially leading to boundary violations or safety issues. Constant observation is warranted to ensure the safety of all clients and to manage the individual's behavior effectively.

A. Disturbed personal identity. B. Risk for injury. C. Ineffective coping. D. Anxiety, panic.

Correct Answer is B

Explanation

A) Disturbed personal identity could be relevant in the context of a mental health issue, but it is not the most immediate concern given the client's current presentation. While it may be important to address over time, it does not take precedence in the acute phase.

B) Risk for injury is the most critical problem to include in the client's plan of care. The client's lack of sleep, pressured speech, and increase in sexual promiscuity indicate a potential manic episode, which can lead to impulsive and unsafe behaviors. Prioritizing the risk for injury ensures the safety of the client and others, making it essential for the immediate care plan.

C) Ineffective coping is a concern that may develop in response to the client's current symptoms. However, addressing immediate safety needs is more urgent than focusing on coping mechanisms at this point.

D) Anxiety and panic might be present, but they are not as clearly defined in the client's current symptoms as the risk for injury. The focus should remain on preventing harm and ensuring the client is safe during this acute episode.

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A client is admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt. Which nursing problem has the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

Correct Answer is D

Explanation

The nurse is admitting a client who has not slept in three days to the inpatient care facility. The client has pressured speech and describes an increase in sexual promiscuity. Which problem should the nurse include in the client's plan of care?

Correct Answer is B

Explanation

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A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. Which action should the nurse implement first?

An employee with a history of hypertension, visits the employee clinic weekly for blood pressure checks. During the assessment the client reports being upset with coworkers and would like to shoot them. Which action should the nurse take first?

A client is admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt. Which nursing problem has the highest priority?