The client's priority nursing diagnosis has been established as risk for self-directed violence: suicide related to multiple losses.
What is the priority outcome for this client?
Be placed on suicide precautions.
Refrain from attempting suicide.
State absence of feelings of powerlessness.
Attend a self-help group daily.
The Correct Answer is B
Choice A rationale
Placing a client on suicide precautions is an intervention (a safety measure) designed to prevent an attempt, not the priority outcome. The outcome is the measurable change in the client's status or behavior that demonstrates goal achievement. While precautions are essential for safety, the ultimate goal is the cessation of the life-threatening behavior itself.
Choice B rationale
Refrain from attempting suicide is the most direct and life-preserving priority outcome for a client with a nursing diagnosis of risk for self-directed violence: suicide. The immediate goal in this high-risk situation is the client's physical safety and survival, which is measurably achieved by the absence of suicidal behavior or gestures. All other goals are secondary to this primary safety objective.
Choice C rationale
Stating absence of feelings of powerlessness is a valuable intermediate or long-term outcome, as powerlessness is a contributing factor to suicidal ideation. However, it addresses the underlying etiology (related to) of the risk, not the life-threatening risk itself. Physical safety must take precedence over emotional or cognitive shifts in the immediate timeframe.
Choice D rationale
Attending a self-help group daily is a therapeutic intervention aimed at long-term coping and recovery, not the immediate priority outcome. While social support and engagement are crucial for preventing recurrence, they do not represent the primary, measurable, and immediate objective of protecting the client's life from imminent self-harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While a "no self-harm" contract can be a useful tool for enhancing patient accountability and commitment to safety, it is a secondary intervention. Given the immediate, high-risk behaviors associated with poor judgment and impulsivity in ADHD, a contract alone does not provide the necessary physical protection or immediate external control required to prevent potential harm, which necessitates continuous direct observation.
Choice B rationale
Assigning a staff member to one-to-one observation is the highest priority intervention for an individual with poor judgment, high risk-taking behaviors, and impulsivity, as it provides constant, direct visual monitoring. This crucial measure prevents the adolescent from acting on sudden, uncontrolled urges to self-harm or engage in dangerous behaviors, ensuring immediate physical safety until the risk level is professionally reassessed by the multidisciplinary treatment team.
Choice C rationale
Frequent discussions are valuable for building therapeutic rapport and exploring underlying psychological factors, coping mechanisms, and alternative behaviors. However, this is a longer-term, insight-oriented strategy that is secondary to the immediate need for physical safety. It does not, by itself, mitigate the acute risk posed by severe impulsivity and poor judgment.
Choice D rationale
Locked seclusion is a form of physical restraint and is a last-resort intervention used only when a patient presents an imminent, extreme danger to self or others and less restrictive measures have failed. Given the scenario, continuous observation (Choice B) is a more therapeutic, less restrictive, and highly effective safety measure, making seclusion an inappropriate initial priority.
Correct Answer is B
Explanation
Choice A rationale
A person with alcoholism who relapses is exhibiting self-destructive behavior, but generally, involuntary commitment requires the person to pose an imminent, immediate danger to themselves or others. While a relapse is concerning, it does not automatically meet the legal criteria for necessary emergency detention unless coupled with acute, life-threatening behavior.
Choice B rationale
An individual with bipolar disorder in a manic phase who has not eaten for four days is exhibiting behavior that leads to severe physical deterioration and poses an imminent, life-threatening danger to self due to malnutrition and dehydration. This meets the legal criterion for involuntary hospitalization (commitment) necessary to protect the client's life.
Choice C rationale
Repeatedly phoning a national TV service is behavior that indicates poor judgment or delusion and may be intrusive or disruptive, but it does not constitute a clear and present danger to the person or others. This is insufficient grounds for legally mandated involuntary confinement, as freedom of speech remains protected.
Choice D rationale
Stopping prescribed antipsychotic medication is considered non-adherence and is likely to lead to a psychotic relapse, which is a significant health concern. However, medication non-adherence alone, without the presence of an immediate danger to self or others, does not satisfy the legal requirements for involuntary commitment.
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