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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
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.
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