Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client's depression alert the nurse to prioritize problems and care by addressing which of the following problems first?

1. A

   Nutritional status

2. B

   Impaired thinking

3. C

   Possible harm to self

4. D

   Rest and activity impairment

Appeared in: NORCET 5 mains

Explanation

Listen in Hindi

• In mental health nursing, patient safety is the absolute highest priority, superseding all other concerns.
• The client's clinical features, especially feelings of hopelessness, worthlessness, and delusional thinking, are significant and well-established risk factors for suicide.
• According to nursing prioritization principles (e.g., Maslow's Hierarchy), safety needs must be addressed before physiological needs like nutrition and sleep or psychological needs like impaired thinking.
• The potential for self-harm is an immediate, life-threatening issue that requires the nurse's first and most urgent attention.

Why Other Options Were Wrong

• Option A: While nutritional status is a vital physiological need and often compromised in depression, it is not the most immediate life-threatening concern compared to the risk of suicide.
• Option B: Impaired thinking, including delusions, is a core symptom of the illness. However, the priority is to manage the dangerous behavior that this thinking can lead to (i.e., self-harm), rather than correcting the thought process itself as the first action.
• Option D: Rest and activity impairment are significant issues that affect the client's quality of life and overall recovery, but they do not present the same immediate risk to life as suicidal ideation.

Related Visual

• Visual 1: Infographic: Maslow's Hierarchy of Needs applied to psychiatric nursing, illustrating that 'Safety' (including prevention of self-harm) is a foundational priority.
• Visual 2: Flowchart: A suicide risk assessment pathway, showing how symptoms like hopelessness and worthlessness trigger specific safety interventions.

Clinical Relevance

• Nursing practice connection: Use the key finding related to Prioritization of nursing care for a client with severe depression and suicide risk to guide bedside assessment, documentation, and the next nursing action.
• A core principle for any nurse is that safety is always the number one priority. In a client with severe depression, this translates to a constant vigilance for suicide risk.
• Any expression of hopelessness, worthlessness, or giving away possessions should be treated as a potential warning sign for suicide and requires immediate assessment.
• It is a dangerous myth that asking a patient directly about suicide will 'plant the idea.' Direct questioning is a critical and necessary assessment tool.

How to Approach the Question

• First, identify the question as a prioritization question by noting the keyword 'first'.
• Next, analyze the clinical scenario. The stem provides a classic picture of severe depression with multiple high-risk features: hopelessness, worthlessness, and delusional thinking.
• Recall fundamental nursing priority frameworks, such as Maslow's Hierarchy of Needs and the 'ABCs' (Airway, Breathing, Circulation). In mental health, 'Safety' functions as the most critical priority, analogous to the ABCs.
• Evaluate each option against the 'Safety First' principle. 'Possible harm to self' is a direct and immediate threat to the patient's safety and life.
• Eliminate the other options because, while they are important aspects of care for depression (nutrition, thinking, rest), they are secondary to the immediate, life-threatening risk of suicide.

Concept Tested & Keywords

• Concept Tested: Prioritization of nursing care for a client with severe depression and suicide risk.
• Stem keywords: severe depression, hopelessness, worthlessness, delusional thinking, prioritize problems
• Lead-in keywords: first
• Clinical cues: The combination of hopelessness, worthlessness, and delusional thinking indicates a high risk for suicide, making safety the top priority.
• Negative lead-in flag: false

Question ID

Q5AzcVW7MfO7fogK55sdfo

Copy ID