Admission data for a newly admitted client who is severely depressed reveal he has lost 20 pounds

Question

over the past month, has chronic low self-esteem, and has both the intent and a plan for committing
suicide.

He has been taking a selective serotonin reuptake inhibitor for 1 week without remission of
symptoms. The priority nursing diagnosis is
a. imbalanced nutrition: less than body requirements.
b. chronic low self-esteem.
c. risk for suicide.
d. ineffective protection.

Answer 1

ANS: C
Risk for suicide is the priority diagnosis when the client has both suicidal ideation and has
developed a plan to carry out the suicidal intent. Imbalanced nutrition and chronic low self-esteem
are viable nursing diagnoses, but these problems do not affect client safety as urgently as would a
suicide attempt. Ineffective protection would be of greater concern if the client were taking
risperidone or an immune suppressant drug.