A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is voluntarily admitted to the psychiatric unit.
Which of the following nursing diagnoses has the highest priority?
Ineffective coping related to inadequate stress management.
Hopelessness related to recent divorce.
Spiritual distress related to conflicting thoughts about suicide and sin.
Risk for suicide related to highly lethal plan.
The Correct Answer is D
Choice A rationale
While ineffective coping related to inadequate stress management is a valid nursing diagnosis, it is not the highest priority in this situation. The client’s life is not immediately at risk due to ineffective coping.
Choice B rationale
Hopelessness related to recent divorce is a significant concern, but it is not the highest priority. The immediate threat to the client’s life is the suicidal ideation with a highly lethal plan.
Choice C rationale
Spiritual distress related to conflicting thoughts about suicide and sin is a potential nursing diagnosis for this client. However, the immediate life-threatening issue takes precedence.
Choice D rationale
Risk for suicide related to highly lethal plan is the highest priority nursing diagnosis. The client has a plan to commit suicide with a handgun, which is a highly lethal method. Immediate intervention is required to ensure the client’s safety.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While the initial days after admission can be stressful and potentially risky for a patient with suicidal ideation, they are not typically considered the highest risk period.
Choice B rationale
Anniversaries of significant life events can indeed trigger emotional distress and potentially increase suicide risk. However, these are specific time points and not a continuous period of heightened risk.
Choice C rationale
The highest risk for self-harm in a patient with a history of suicidal ideation is often approximately 2 weeks after starting antidepressant medication. This is because as their mood begins to lift, they may still have suicidal thoughts but now have the energy to act on them.
Choice D rationale
While family visits can be emotionally charged and potentially distressing, they do not typically represent the highest risk period for self-harm.
Correct Answer is A
Explanation
The management of delirium is indeed dependent on its cause, with the primary focus being to address the root cause. This could involve treating an underlying infection, adjusting a medication regimen, or addressing other factors that may have triggered the delirium.
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