Which of the options below would be a priority nursing diagnosis?
Anxiety
Ineffective coping
Chronic low self-esteem
Self-harm
The Correct Answer is D
Choice A Reason:
Anxiety is incorrect. While anxiety is a valid concern, it may not be an immediate threat to the individual's safety.
Choice B Reason:
Ineffective coping is incorrect. This is relevant, but it doesn't address the urgency associated with potential self-harm.
Choice C Reason:
Chronic low self-esteem is incorrect. Low self-esteem is a significant issue, but it may not require immediate intervention compared to the risk of self-harm.
Choice D Reason:
Self-harm is correct. Assessing and addressing the risk of self-harm takes precedence, as it involves ensuring the immediate safety and well-being of the individual. Once the risk of self-harm is addressed, the nurse can then explore and address other related concerns, such as anxiety, coping mechanisms, and self-esteem.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
"Your husband is making really good progress" This statement assumes a positive or negative judgment about the husband's progress without first understanding the spouse's concerns. It may not address the spouse's immediate emotional needs or allow them to express their feelings.
Choice B Reason:
"Crying helps us let things out and we feel better". While this statement acknowledges the act of crying as a way to express emotions, it doesn't directly address the specific concerns of the spouse or invite further communication about the issues causing distress.
Choice C Reason:
"Tell me what is concerning you. “This is a therapeutic nursing response because it encourages the spouse to express their concerns and share their feelings. It opens up communication and allows the nurse to better understand the specific issues or worries that the spouse is experiencing. This response demonstrates active listening and a genuine interest in the spouse's perspective, fostering a supportive and empathetic therapeutic relationship.
Choice D Reason:
"Did your husband say something to upset you?" This question assumes that the spouse's distress is solely related to something the husband said. It may not be the most open-ended or empathetic way to encourage the spouse to share their concerns and might direct the focus too narrowly.
Correct Answer is B
Explanation
Choice A Reason:
"It might help you feel better if you talk about it." While encouraging communication is generally good, the client has clearly expressed a desire not to talk at the moment. Pressuring them to talk may not be beneficial.
Choice B Reason:
"I'll just sit here with you for a few minutes then." This response acknowledges the client's need for solitude while showing a willingness to provide presence and support. It respects the client's autonomy and allows them to lead the interaction.
Choice C Reason:
"I understand; I've felt like that before, too." While expressing empathy can be helpful, it's important not to overshadow the client's experience by sharing personal feelings at this moment.
Choice D Reason:
"Why are you feeling so down?" This question may feel intrusive and may not be well-received by the client, especially when they've indicated a preference not to talk. It's important to approach the conversation with sensitivity and respect for the client's boundaries.
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