When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?
Ineffective breathing pattern.
Risk for injury.
Ineffective coping.
Impaired comfort.
The Correct Answer is A
Choice A rationale: Ineffective breathing pattern is the highest priority nursing problem. Aspiration of a caustic material can lead to respiratory compromise, and ensuring adequate oxygenation takes precedence.
Choice B rationale: Risk for injury is important, but respiratory concerns associated with aspiration take priority in this situation.
Choice C rationale: Ineffective coping is relevant but does not take precedence over addressing immediate physiological needs such as breathing.
Choice D rationale: Impaired comfort is important, but the priority is to ensure the client's respiratory status and address potential complications of caustic material aspiration.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Asking about a bad experience may provide additional information, but it does not directly address the behavioral aspect of obsessive-compulsive disorder (OCD).
Choice B rationale: This response shows empathy and curiosity and invites the client to explore their cognitive processes behind their compulsive behavior. The nurse can help the client identify and challenge their irrational or distorted thoughts that fuel their anxiety and drive them to check the locks repeatedly.
Choice C rationale: Acknowledging that repeating the same behavior helps diminish anxiety might reinforce the client's belief that checking the locks is necessary and beneficial, which could prevent them from seeking alternative coping strategies.
Choice D rationale: Stating that feelings of being driven are related to anxiety is a general observation and may not contribute to a deeper understanding of the client's experience with OCD.
Correct Answer is B
Explanation
Choice A rationale: "Do you think someone is trying to harm you?" is a leading question and may contribute to the client's paranoid thoughts. It is important to explore the client's concerns without making assumptions.
Choice B rationale: "What makes you think people are stalking you?" is an open-ended question that invites the client to share more about her experiences and thought processes. It allows for a deeper exploration of the client's perceptions.
Choice C rationale: "It sounds like this experience is frightening for you" is a closed statement and may not encourage the client to elaborate on her thoughts. Open-ended questions are more effective in this situation.
Choice D rationale: "I know you are frightened, but no one is stalking you" is a dismissive statement that may invalidate the client's feelings. It is imp
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