A nurse is assessing a patient diagnosed with major depressive disorder. The patient states, 'I don't feel anything anymore. I don't care about anything.' Which nursing diagnosis is most appropriate for this patient?

Correct Answer: A

Rationale: The correct answer is A: Hopelessness. The patient's statement reflects a sense of despair and lack of interest, which aligns with the defining characteristics of hopelessness in major depressive disorder. The patient expressing not feeling anything and lacking care indicates a deep sense of hopelessness. Impaired social interaction (B) does not capture the core issue of hopelessness presented by the patient. Risk for self-directed violence (C) is not supported by the patient's statement, as there is no indication of self-harm. Powerlessness (D) does not fully encompass the patient's emotional state of hopelessness.

Correct Answer: D

Rationale: The correct answer is D: Anxiety. This nursing diagnosis is the most appropriate because the patient is experiencing excessive worry and fear, which aligns with the defining characteristics of generalized anxiety disorder. Impaired social interaction (A) is not the best choice as the patient's primary concern is anxiety, not social interaction. Ineffective coping (B) may be a result of anxiety but does not address the primary issue. Disturbed thought processes (C) typically involves alterations in cognitive processes, which are not described in the scenario.

Correct Answer: A

Rationale: The correct answer is A because assessing the patient's suicidal thoughts and plan is the priority in this situation to ensure patient safety. By asking about suicidal ideation, the nurse can determine the level of risk and take appropriate actions to prevent self-harm. Choice B is incorrect as encouraging the patient to talk about their feelings is important but not the priority when immediate safety is at stake. Choice C is incorrect as simply reassuring the patient without assessing their suicidal ideation can be dangerous if the patient is at high risk of self-harm. Choice D is also incorrect as providing positive affirmations and support may not address the underlying risk of suicidal ideation.

Correct Answer: B

Rationale: The correct answer is B because staying with a tearful patient demonstrates empathy and emotional support, fostering a therapeutic relationship that can enhance growth. This action shows the patient that their feelings are valid and valued, promoting trust and openness. Choices A, C, and D do not directly address the emotional needs of the patient or show positive regard, which is essential for growth in this context. Making rounds daily focuses on tasks, administering medication is necessary but not directly related to emotional support, and examining personal feelings about a patient is more reflective than actively showing support.

Correct Answer: A

Rationale: The correct answer is A. Asking the patient directly about thoughts of self-harm or suicide is the priority intervention because it allows the nurse to assess the patient's risk and take appropriate actions to ensure safety. It is essential to address potential suicidal ideation promptly. Encouraging group therapy (B) may be beneficial but is not as urgent as assessing for suicidal thoughts. Offering reassurance and support (C) is important but does not directly address the risk of suicide. Monitoring for signs of agitation or psychotic symptoms (D) is also important but not as crucial as directly assessing for suicidal ideation.