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 B
Explanation
Choice A Reason:
"If it weren't for you and the hours we've spent talking, I don't think I would be on my way to getting my anxiety under control." While this statement acknowledges the importance of the nurse-patient relationship in helping with anxiety, it might imply a somewhat dependent stance. The ideal therapeutic relationship encourages patients to gain skills and tools to manage their issues independently.
Choice B Reason:
"I appreciate the time you spent with me. I have a better understanding of what I can do to manage my problem." This statement reflects the patient's acknowledgment of the nurse's support and guidance, resulting in a positive impact on the patient's understanding and ability to manage their concerns. It emphasizes the constructive nature of the nurse-patient relationship and the effectiveness of the interactions in addressing the patient's needs.
Choice C Reason:
"I really need to talk with you. You always give me good advice about how to address my anger issues." While seeking support and advice from the nurse is positive, the emphasis on always receiving good advice might suggest a more directive approach rather than collaborative exploration and problem-solving, which is often a goal in therapeutic relationships.
Choice D Reason:
"You've been kind to me when I was at a low point. Knowing you've had low points too was such a help. “While mutual understanding and empathy are crucial in the nurse-patient relationship, the statement may focus more on the nurse's experiences rather than the patient's progress or understanding. The primary focus should be on the patient's needs and growth.
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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