A client who recently 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 scenario. The client’s threat to commit suicide with a handgun indicates a clear and immediate risk.
Choice B rationale
Hopelessness related to recent divorce is a significant concern and may contribute to the client’s suicidal ideation. However, the immediate threat of suicide takes precedence.
Choice C rationale
Spiritual distress related to conflicting thoughts about suicide and sin may be a factor in the client’s mental state, but it is not the immediate concern. The client’s life is in danger, which must be addressed first.
Choice D rationale
Risk for suicide related to a highly lethal plan is the highest priority nursing diagnosis. The client has a clear plan (using a handgun) and means (access to a handgun), indicating a high risk for suicide.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
The correct answer is Choice A and B.
A score of 1 to 10 on the Global Assessment Functioning (GAF) scale indicates that a client is in persistent danger of severely hurting self or others or has a persistent inability to maintain minimal personal hygiene.
Correct Answer is D
Explanation
Bright colors in a psychiatric unit environment are often perceived as stimulating. They can enhance alertness and motivation in patients.
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