A patient states, 'I’m not worth anything I have negative thoughts about myself I feel anxious and shaky all the time Sometimes I feel so sad that I want to go to sleep and never wake up' Which nursing intervention should have the highest priority?

Correct Answer: D

Rationale: In this scenario, the highest priority nursing intervention is D) Suicide precautions. This is the most critical because the patient's statement indicates a high risk for suicide ideation or intent. It is essential to ensure the safety and well-being of the patient by implementing measures to prevent self-harm. Option A) Self-esteem-building activities may be beneficial in the long term, but the immediate concern is the patient's safety. Option B) Anxiety self-control measures are important but not the highest priority when there is a risk of suicide. Option C) Sleep enhancement activities are relevant but do not address the immediate risk of self-harm. In an educational context, this question highlights the importance of prioritizing nursing interventions based on the urgency of the patient's needs. Understanding the hierarchy of needs and the critical nature of certain symptoms, such as suicidal ideation, is essential for providing effective and timely care in behavioral nursing. Nurses must be able to quickly assess and prioritize interventions to ensure patient safety and well-being.

Correct Answer: C

Rationale: In the context of behavioral nursing, asking the client to describe their problems serves the purpose of obtaining information about their perception of the problem (Option C). This is the correct answer because understanding how the client perceives their issues is crucial for assessing their mental and emotional state. By allowing the client to articulate their problems in their own words, the nurse gains insight into their thoughts, emotions, and concerns, which is essential for developing a holistic care plan. Option A (admitting diagnosis) is incorrect because the question is focused on the client's subjective experience rather than a formal medical diagnosis made by healthcare professionals. Option B (communication skills) is incorrect as the question is not primarily assessing the client's ability to communicate effectively but rather their personal experiences and feelings. Option D (personal needs) is also incorrect as the question is more about exploring the client's perception of their problems rather than their broader personal needs. In an educational context, understanding the rationale behind this question is essential for nurses to develop effective communication skills, build rapport with clients, and provide person-centered care. By recognizing the significance of exploring the client's perception of their problems, nurses can establish a therapeutic relationship based on trust and empathy, leading to better outcomes in behavioral nursing practice.

Correct Answer: B

Rationale: Judgment refers to the ability to interpret one's environment and situation correctly and to adapt one's own behavior and decisions accordingly. This question will elicit information about the client's problem-solving and decision-making abilities. The other choices do not assess the concept of judgment.

Correct Answer: A

Rationale: With circumstantial thinking, the client eventually answers a question but only after giving excessive unnecessary detail. Echolalia is repetition or imitation of what someone else says. Flight of ideas is excessive amount and rate of speech composed of fragmented or unrelated ideas. Neologisms are invented words that have meaning only for the client.

Correct Answer: A

Rationale: Clients have the right to treatment in the least restrictive environment appropriate to meet their needs. It means that a client does not have to be hospitalized if he or she can be treated in an outpatient setting or in a group home. It also means that the client must be free of restraint or seclusion unless it is necessary. Verbal and behavioral techniques should be instituted before physical measures such as sedation, restraint, or seclusion.