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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Ideas of reference involve the belief that casual events, people’s remarks, or elements in the environment have a particular and unusual meaning specifically for oneself. This is not what is being described in the question.
Choice B rationale
Perseveration is the repetition of a particular response, such as a word, phrase, or gesture, despite the absence or cessation of a stimulus. It is usually caused by a brain injury or other organic disorder. This is not what is being described in the question.
Choice C rationale
Flight of ideas is a symptom of a thought disorder that causes a rapid shift from one idea to another. This symptom is often seen in conditions like bipolar disorder, particularly during manic episodes. This matches the description given in the question.
Choice D rationale
Confabulation is a memory disturbance in which a person confuses imagined scenarios with actual memories, with no intent to deceive. This is not what is being described in the question.
Correct Answer is D
Explanation
Choice A rationale
Asking the client to make a verbal contract to not harm themselves is a common strategy used in suicide prevention. However, it is not the primary responsibility of the practical nurse in this scenario.
Choice B rationale
Returning the client to the waiting room with the spouse is not the most appropriate action. The client’s safety is the top priority, and they should be closely monitored due to their erratic behavior and expressions of despair.
Choice C rationale
Documenting that the client is not currently suicidal is important, but it is not the primary responsibility of the practical nurse in this scenario. The client’s non-verbal cues (shrugging their shoulders) suggest they may be at risk.
Choice D rationale
The primary responsibility of the practical nurse in this scenario would be to place the client in an ideal situation with one-on-one observation. This ensures the client’s safety and allows for immediate intervention if necessary.
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