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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A rationale: Asking the client about recent substance use is essential in assessing potential intoxication or withdrawal, which could contribute to the client's confused state. However, performing a mental status exam is the most important action to take.

Choice B rationale: The most important action for the nurse to take is to perform a mental status exam. This will help the nurse to assess the client's level of consciousness, orientation, memory, attention, mood, affect, thought process, and judgment. The mental status exam will also help the nurse to identify any signs of psychosis, delirium, dementia, or other mental disorders that may explain the client's behavior. Choice C rationale: Assessing the client from head-to-toe is a general nursing action but does not address the immediate need related to potential substance use. Choice D rationale: Determining the number of previous hospitalizations is relevant but does not address the current concern of substance use contributing to confusion.

A. Initiates an exercise program to help deal with stress. B. Identifies four positive personal traits. C. Returns to previous level of functioning. D. Describes what is needed in a romantic relationship.

Correct Answer is C

Explanation

Choice A rationale: Initiating an exercise program may be a helpful intervention, but the primary goal for this client following a drug overdose and romantic relationship issues is to return to the previous level of functioning.

Choice B rationale: Identifying positive personal traits is a positive goal but may not be the most immediate priority for this client.

Choice C rationale: Returning to the previous level of functioning is the primary goal for hospitalization. This goal involves restoring the client's ability to manage daily life and cope with stressors.

Choice D rationale: Describing what is needed in a romantic relationship is important, but the immediate focus is on the client's overall functioning and safety.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A college student is admitted to the mental health unit following a drug overdose. The student tells the nurse about the overdose following the end of a romantic relationship. Which is the primary goal for hospitalization that should be included in this client's plan of care?

Correct Answer is C

Explanation

The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? Select all that apply.

A middle-aged female client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse, "I want to find out why these people are stalking me!" Which response should the nurse provide?

During a high school class on substance abuse, a student tells the group, "If I tried cocaine, I know I could handle it. I know when to stop." Which response is best for the nurse to provide?

A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the reason for the nurse's behavior?

The nurse is assessing a client with postpartum depression for changes in the mood and cognitive state. Which subjective finding(s) should the nurse identify that are consistent with postpartum depression? Select all that apply.

The nurse is providing teaching to a client and family about schizophrenia before discharge from an inpatient facility. The nurse should instruct the family to notify the healthcare provider when which behavior is observed?

The nurse is reviewing an intake mental health assessment with a client who is seeking services for depression. The client reports feeling dizzy, excessively tired, experiencing headaches, and back pain. Which symptom should the nurse suspect is related to the client's feelings of depression?