RN CARE HOPE MENTAL HEALTH HESI PROCTORED EXAM
An adult client presents to the community mental health center accompanied by the client’s spouse who reports that the client has been acting impulsively. The client has spent a large amount of money lately, made several last-minute decisions to take trips, sleeps only 2 to 4 hours a night, and has lost 33 pounds (15 kg) in the last 2 months. Which nursing problem has the greatest nursing priority?
Explanation & Rationale
A. While sleep deprivation is a concern, the client's impulsive behavior poses a greater immediate risk, making "Risk for self-directed violence related to impulsive behavior" the priority. B. Ineffective coping may be a contributing factor, but the risk of self-directed violence takes precedence as the primary concern. C. The client's impulsive behavior increases the risk of self-directed violence, making it the most urgent nursing priority. D. Imbalanced nutrition is a concern, but the immediate risk of self-directed violence requires more immediate attention.
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