A patient's employment is terminated, and major depressive disorder develops shortly afterward. The patient says to the nurse, 'I'm not worth the time you spend with me. I'm the most useless person in the world.' Which nursing diagnosis applies?

Correct Answer: C

Rationale: The correct nursing diagnosis is C: Situational low self-esteem. The patient's statement reflects a negative self-perception related to the recent termination of employment, indicating situational low self-esteem. This diagnosis focuses on a specific event affecting self-worth. Choice A, Powerlessness, would be more appropriate if the patient expressed a lack of control in their situation. Choice B, Defensive coping, would apply if the patient was using defensive mechanisms to protect themselves from the emotional impact of job loss. Choice D, Disturbed personal identity, would be relevant if the patient had a significant disruption in self-concept beyond just low self-esteem.

Correct Answer: A

Rationale: The correct answer is A because ensuring the patient is in a safe environment and monitoring for physical harm is the top priority during acute mania. This intervention focuses on preventing any harm to the patient or others, which is crucial in managing acute mania. It prioritizes safety and can help prevent any potential dangerous situations. Encouraging group activities (choice B) may not be effective during acute mania as the patient may not be able to participate safely. Administering a sedative (choice C) without ensuring safety first can lead to potential risks. Offering medication (choice D) should be done after ensuring the patient's safety.

Correct Answer: C

Rationale: Step 1: Chronic trauma refers to repeated exposure to traumatic events over a prolonged period, such as ongoing abuse and neglect in this case. Step 2: The adolescent has experienced abuse and neglect since early childhood, indicating a long-term and persistent traumatic experience. Step 3: Vicarious trauma involves indirect exposure to trauma through witnessing or hearing about others' experiences. Step 4: Acute trauma refers to a single traumatic event with immediate impact, not a prolonged pattern like chronic trauma. Step 5: Historical trauma relates to collective trauma experienced by a group over generations, not an individual's ongoing abuse and neglect. Summary: Choice C is correct because it best describes the repeated and prolonged nature of the adolescent's traumatic experiences, while the other choices do not align with the specific circumstances presented.

Correct Answer: B

Rationale: The correct answer is B because the statement "I'm going to give my sister my pottery collection when I get home" indicates future planning, suggesting the client may not see themselves owning the collection in the future due to suicidal ideation. Choices A, C, and D do not directly relate to suicidal ideation as they focus on positive activities or future plans that do not indicate self-harm intentions.

Correct Answer: C

Rationale: The correct answer is C: Severe weight loss and restriction of food intake. In anorexia nervosa, patients typically exhibit extreme fear of gaining weight, leading to severe restriction of food intake resulting in significant weight loss. Monitoring for this sign is crucial to assess the severity of the disorder and plan appropriate interventions. Incorrect choices: A: Extreme weight gain and bloating - This is not indicative of anorexia nervosa as patients with this disorder typically experience significant weight loss. B: Excessive exercise and compulsive eating - While excessive exercise can be a symptom of anorexia nervosa, compulsive eating is more commonly associated with binge eating disorder. D: Binge eating followed by purging behaviors - This pattern of behavior is characteristic of bulimia nervosa, not anorexia nervosa.