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
While fostering a social relationship can be a part of therapeutic communication, it is not the primary goal. The main focus is on the client’s needs and concerns.
Choice B rationale
Focusing on the attitude of the client is not the primary goal of therapeutic communication. The main goal is to understand the client’s experiences and feelings.
Choice C rationale
The primary goals of therapeutic communication are to focus on the client and to build a rapport. This involves understanding the client’s needs, concerns, and emotions effectively.
Choice D rationale
Focusing on the staff member and building rapport is not the primary goal of therapeutic communication. The main focus should be on the client.
Correct Answer is B
Explanation
Step 1 is to determine the amount of medication to administer. The order is for Haldol 2mg IM stat. The available medication is Haldol 5mg/ml. To find out how many ml’s to administer, you would divide the ordered dose by the available dose. So, 2mg ÷ 5mg/ml = 0.4 ml.
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