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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Asking the client what they think should happen is vague and does not offer any direction or support.
Choice B rationale: This response encourages is vague and does not offer any direction or support but instead puts the burden of decision-making on the client who is overwhelmed and distressed.
Choice C rationale: Inquiring about the seriousness of the collision is important but may not be the most immediate concern when the client is seeking guidance on what to do.
Choice D rationale: This response shows empathy and concern for the client's well-being and helps the client take action to cope with the crisis.
Correct Answer is A
Explanation
Choice A rationale: Providing information about available community resources is crucial during the discharge phase to support the client's transition to the community and ongoing care.
Choice B rationale: Exploring the client's feelings related to discharge is important, but providing practical information about available resources is more immediate and can aid in the client's continuity of care.
Choice C rationale: Asking the client to describe alternative coping mechanisms is relevant, but connecting the client with community resources is a more immediate concern during the discharge phase.
Choice D rationale: Discussing potential medication side effects is important, but linking the client to community resources takes precedence during the discharge process.
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