6. A client's spouse reveals ongoing infidelity in their relationship. A nurse identifies that this client is at increased risk for:
6. A client's spouse reveals ongoing infidelity in their relationship. A nurse identifies that this client is at increased risk for:
Test-Taking Tip
Eliminate Answers 1, 2, and 4 because these are not risk-related nursing diagnoses. Remember: priority problems are those that pose a threat to the client's homeostasis.
Content Area: Mental Health, Adult Health, Sexually Transmitted Infections; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Safe and Effective Care Environment/Safety and Infection Control/Standard/Transmission-based/Other Precautions
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Answer 1 is incorrect as this nursing diagnosis is not necessarily risk related. Ineffective protection would be a problem if the client were immunocompromised, which is not known at this time. Answer 2 is incorrect because, although the client may experience pain, it is not a common problem with sexually transmitted infections. Answer 3 is correct because, if sexual encounters were unprotected, this may place the client at risk for sexually transmitted infections, which could lead to injury, permanent dysfunction, and possible infection-related problems. Answer 4 is incorrect because, even though knowledge deficit about sexually transmitted infections is likely, it is not a priority.
