Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is voluntarily admitted to the psychiatric unit.
Which of the following nursing diagnoses has the highest priority?
A. Ineffective coping related to inadequate stress management.
While ineffective coping related to inadequate stress management is a valid nursing diagnosis, it is not the highest priority in this situation. The client’s life is not immediately at risk due to ineffective coping.
B. Hopelessness related to recent divorce.
Hopelessness related to recent divorce is a significant concern, but it is not the highest priority. The immediate threat to the client’s life is the suicidal ideation with a highly lethal plan.
C. Spiritual distress related to conflicting thoughts about suicide and sin.
Spiritual distress related to conflicting thoughts about suicide and sin is a potential nursing diagnosis for this client. However, the immediate life-threatening issue takes precedence.
D. Risk for suicide related to highly lethal plan.
Risk for suicide related to highly lethal plan is the highest priority nursing diagnosis. The client has a plan to commit suicide with a handgun, which is a highly lethal method. Immediate intervention is required to ensure the client’s safety.
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Full Explanation
Choice A rationale
While ineffective coping related to inadequate stress management is a valid nursing diagnosis, it is not the highest priority in this situation. The client’s life is not immediately at risk due to ineffective coping.
Choice B rationale
Hopelessness related to recent divorce is a significant concern, but it is not the highest priority. The immediate threat to the client’s life is the suicidal ideation with a highly lethal plan.
Choice C rationale
Spiritual distress related to conflicting thoughts about suicide and sin is a potential nursing diagnosis for this client. However, the immediate life-threatening issue takes precedence.
Choice D rationale
Risk for suicide related to highly lethal plan is the highest priority nursing diagnosis. The client has a plan to commit suicide with a handgun, which is a highly lethal method. Immediate intervention is required to ensure the client’s safety.
Similar Questions
Ativan 1mg IM is ordered, Ativan is available in mg/mL. How many mLs will you administer?
Full Explanation
Step 1 is to determine the volume to administer. The order is for 1mg and Ativan is available in mg/mL. So, 1mg ÷ 1mg/mL = 1mL.
Therefore, you will administer 1mL.
Upon entering a mental health care system, clients undergo a thorough assessment, followed by the creation of a mental health treatment plan. What are the objectives of this treatment plan? (Select all that apply.)
A. It serves as a tool for communication and coordination of care.
A mental health treatment plan serves as a tool for communication and coordination of care. It helps to ensure that all healthcare professionals involved in a client’s care have access to the same information, promoting consistent and coordinated care.
B. It is used to evaluate the effectiveness of interventions.
The treatment plan is used to evaluate the effectiveness of interventions. By comparing the client’s progress to the goals set out in the treatment plan, healthcare professionals can determine whether the interventions are working or if adjustments need to be made.
C. It acts as a guide for the planning and implementation of care.
The treatment plan acts as a guide for the planning and implementation of care. It outlines the strategies and interventions to be used, helping to ensure that the care provided is aligned with the client’s needs and goals.
D. It is a means of monitoring the client’s progress.
The treatment plan is a means of monitoring the client’s progress. Regular reviews of the treatment plan can provide valuable insights into how the client is progressing and whether any changes to the plan are required.
Full Explanation
Choice A rationale
A mental health treatment plan serves as a tool for communication and coordination of care. It helps to ensure that all healthcare professionals involved in a client’s care have access to the same information, promoting consistent and coordinated care.
Choice B rationale
The treatment plan is used to evaluate the effectiveness of interventions. By comparing the client’s progress to the goals set out in the treatment plan, healthcare professionals can determine whether the interventions are working or if adjustments need to be made.
Choice C rationale
The treatment plan acts as a guide for the planning and implementation of care. It outlines the strategies and interventions to be used, helping to ensure that the care provided is aligned with the client’s needs and goals.
Choice D rationale
The treatment plan is a means of monitoring the client’s progress. Regular reviews of the treatment plan can provide valuable insights into how the client is progressing and whether any changes to the plan are required.
True or False: The management of delirium is dependent on its cause, with the primary focus being to address the root cause.
A. True
B. False
Full Explanation
The management of delirium is indeed dependent on its cause, with the primary focus being to address the root cause. This could involve treating an underlying infection, adjusting a medication regimen, or addressing other factors that may have triggered the delirium.