A client with depression is admitted to the hospital following a suicide attempt. Which nursing diagnosis would be most appropriate at this time?

Disturbed body image related to depression

Imbalanced nutrition: Less than body requirements related to depression

Hygiene self-care deficit related to depression

Risk for self-directed violence related to depression

Answer and Explanation

The Correct Answer is D

A. Disturbed body image related to depression: While body image disturbances can occur with depression, it is not the primary concern following a suicide attempt.

B. Imbalanced nutrition: Less than body requirements related to depression: While nutritional imbalances may be present in clients with depression, the most pressing concern after a suicide attempt is safety.

C. Hygiene self-care deficit related to depression: A self-care deficit is often present in depression but is not the most urgent diagnosis after a suicide attempt.

D. Risk for self-directed violence related to depression: This is the most appropriate nursing diagnosis following a suicide attempt, as it directly addresses the client’s risk of harm to themselves.

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Correct Answer is A

Explanation

A. Hematologic spread: Hematologic spread (through the bloodstream) is a common mechanism for metastasis to distant organs like bones and liver. This is the most likely mechanism for the spread described.

B. Lymphatic circulation: Lymphatic spread often leads to regional lymph nodes rather than distant organs like bones and liver.

C. Invasion: Invasion involves local spread into adjacent tissues but does not typically account for distant metastasis.

D. Angiogenesis: Angiogenesis refers to the formation of new blood vessels to supply the tumor, not the mechanism by which cancer cells spread to distant sites.

A. Tolerance B. Addiction C. Alcoholism D. Relapse

Correct Answer is A

Explanation

A. Tolerance: Tolerance occurs when an individual requires increasing amounts of a substance to achieve the same effect. This can explain why a person with a high blood alcohol level might not appear intoxicated if they have developed tolerance.

B. Addiction: Addiction is a chronic disease involving compulsive substance use. While related to tolerance, addiction itself does not specifically explain the lack of observable intoxication symptoms.

C. Alcoholism: Alcoholism is a condition involving dependency on alcohol. It can involve tolerance, but the term "alcoholism" does not specifically address the immediate observation of high alcohol levels without visible intoxication.

D. Relapse: Relapse refers to returning to substance use after a period of abstinence. It does not specifically explain the lack of visible intoxication despite high blood alcohol levels.

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A client with depression is admitted to the hospital following a suicide attempt. Which nursing diagnosis would be most appropriate at this time?

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