A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority?

Correct Answer: C

Rationale: In the context of a person intentionally overdosing on antidepressants, the nursing diagnosis with the highest priority is "C) Risk for suicide." This is because the individual's immediate safety is the primary concern when dealing with a suicide attempt. Assessing and managing the risk for suicide takes precedence over other nursing diagnoses in this critical situation. Option A) Powerlessness may be a valid nursing diagnosis for this scenario, as the individual may indeed feel powerless, but addressing the immediate risk of suicide is of higher priority. Option B) Social isolation is also important to address, as social support plays a role in mental health, but it is secondary to ensuring the person's safety in a psychiatric emergency. Option D) Compromised family coping is relevant, considering the impact on the individual's family, but in an acute psychiatric emergency, the immediate risk of suicide takes precedence over addressing family coping mechanisms. Educationally, this question highlights the critical thinking skills required in psychiatric emergencies. It emphasizes the importance of prioritizing nursing interventions based on the urgency of the situation and the potential for harm. Understanding the hierarchy of nursing diagnoses in psychiatric emergencies is crucial for providing effective and timely care to individuals in crisis.

Correct Answer: C

Rationale: The correct answer is C) Attending a self-help group for survivors. This intervention is the most appropriate for the distressed family and friends of someone who has committed suicide because it provides a supportive environment where individuals can share their experiences, emotions, and coping strategies with others who have gone through a similar loss. Being part of a self-help group can help reduce feelings of isolation, provide validation of emotions, and offer practical advice on how to navigate the grieving process. Option A, participating in reminiscence therapy, is not the most appropriate intervention in this scenario as it focuses on recalling past events and experiences to promote emotional healing. While reminiscence therapy can be beneficial in other contexts, it may not address the immediate needs of individuals dealing with the shock and grief of a recent suicide. Option B, psychological postmortem assessment, is also not the most suitable intervention for the distressed family and friends as it involves a formal evaluation of the deceased individual's mental health history and circumstances leading up to the suicide. While this assessment may be valuable for understanding the factors contributing to the suicide, it does not directly address the emotional needs of the bereaved individuals. Option D, contracting for at least two sessions of group therapy, may provide therapeutic support, but it lacks the specific focus on shared experiences and support from others who have experienced a similar loss, which is a key component of self-help groups for suicide survivors. In an educational context, understanding the most appropriate interventions for individuals affected by suicide is crucial for healthcare professionals working in psychiatric emergencies. By recognizing the unique needs of those grieving a suicide and knowing how to guide them towards effective support services, nurses can play a vital role in promoting healing and resilience in the face of such a traumatic event.

Correct Answer: D

Rationale: The correct answer is D) Risk for other-directed violence. In a situation where a patient has been arrested for breaking windows, the priority nursing diagnosis is identifying the risk for other-directed violence. This is crucial for ensuring the safety of not only the patient but also others around them. It is important to assess the potential for the patient to cause harm to others, especially considering their behavior of breaking windows, which could escalate to physical harm towards individuals. Option A) Risk for injury is not the priority in this scenario because the focus is on the risk the patient poses to others rather than self-injury. Option B) Ineffective coping may be relevant, but it is secondary to the immediate concern of potential violence towards others. Option C) Impaired social interaction is not the priority at this moment because the main concern is the safety and well-being of those around the patient. Educationally, understanding the prioritization of nursing diagnoses in psychiatric emergencies is vital for providing effective and timely care. Recognizing and addressing the risk for violence is crucial in ensuring the safety of all individuals involved and preventing potential harm. By prioritizing this nursing diagnosis, nurses can implement appropriate interventions to manage and mitigate the risk of other-directed violence.

Correct Answer: B

Rationale: In psychiatric emergencies, administering medication safely and effectively is crucial in managing acute symptoms. Option B, accompanied by 3 staff, is the correct choice because it prioritizes safety for both the patient and staff. The presence of multiple staff members ensures that the medication administration process is conducted securely and reduces the risk of potential harm. Option A is incorrect as it lacks the necessary support and supervision for a potentially agitated or uncooperative patient. Option C is inappropriate as using physical restraint like a basket-hold should only be considered as a last resort in extreme cases due to the risk of escalation and harm. Option D is also incorrect as involving a guard may further escalate the situation and compromise the therapeutic relationship between the patient and healthcare provider. Educationally, this question highlights the importance of proper medication administration procedures in psychiatric settings. It emphasizes the significance of teamwork, communication, and safety measures when dealing with patients experiencing psychiatric emergencies. By choosing option B, nurses can ensure the well-being of both the patient and themselves while delivering timely and appropriate care.

Correct Answer: A

Rationale: In psychiatric emergencies, managing angry patients without resorting to violence is crucial for ensuring both patient and staff safety. Option A, which suggests helping the patient identify and challenge anger-inducing thoughts, is the correct choice. This intervention is rooted in cognitive-behavioral strategies, which aim to modify maladaptive thought patterns. By assisting the patient in evaluating and replacing irrational thoughts with more rational ones, nurses can help de-escalate the situation and promote self-awareness and self-regulation skills in the patient. Options B and C, advocating for negative reinforcement and aversive conditioning, respectively, are not appropriate in this context. These approaches can escalate aggression, violate ethical principles, and potentially lead to further distress or trauma for the patient. Restraint and seclusion should only be used as a last resort when imminent harm is likely. Aversive conditioning techniques are not recommended in mental health care due to their potential for harm and lack of evidence-based support. Option D, administering medication, may be necessary in some cases, but it should not be the first-line intervention for managing anger in psychiatric emergencies. Medications should be prescribed based on a thorough assessment by a qualified healthcare provider and in conjunction with other therapeutic interventions. Educationally, understanding the principles of de-escalation techniques, cognitive-behavioral strategies, and ethical considerations in psychiatric care is essential for nurses working in mental health settings. This question highlights the importance of using evidence-based, patient-centered approaches to manage challenging behaviors and promote positive outcomes for individuals experiencing psychiatric emergencies.