A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?
Determining if the client has psychotic thinking
Asking the client to identify the cause of the crisis
Identifying the client's coping skills
identifying the client's support systems
The Correct Answer is A
The highest priority assessment in this situation is to determine if the client has psychotic thinking. Psychotic thinking can indicate a severe mental health condition that requires immediate attention and intervention. If the client is experiencing psychotic symptoms, they might be at risk of harming themselves or others. Identifying and addressing psychotic thinking is crucial to ensure the safety and well-being of the client and those around them.
B. Asking the client to identify the cause of the crisis.
While understanding the cause of the crisis is important for providing appropriate care, it is not the highest priority. Psychotic thinking or risk of harm takes precedence over understanding the cause.
C. Identifying the client's coping skills.
Coping skills are important for managing the crisis and promoting the client's well-being, but assessing for psychotic thinking and immediate safety concerns comes before evaluating coping skills.
D. Identifying the client's support systems.
Support systems are valuable for the client's overall recovery, but they are not as time-sensitive as assessing for psychotic thinking or imminent safety risks. Identifying support systems can come after addressing the immediate concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Tactile hallucination: Incorrect
Tactile hallucinations involve false sensations of touch, such as feeling something on the skin that isn't there. While these hallucinations can be distressing, they are not typically considered a priority over other types of hallucinations, especially those that might pose more immediate risks.
B. Command hallucination: Correct
Command hallucinations involve hearing voices that command the individual to take specific actions, often harmful ones. These types of hallucinations are considered a significant priority because they can lead to dangerous behaviors, self-harm, or harm to others. Addressing and managing command hallucinations promptly is crucial to ensure the safety of the individual and those around them.
C. Visual hallucination: Incorrect
Visual hallucinations involve seeing things that aren't actually present. While these can be distressing, they are generally considered less urgent compared to command hallucinations, which can directly lead to risky actions.
D. Gustatory hallucination: Incorrect
Gustatory hallucinations involve false perceptions of taste. While these can be unsettling, they are not typically considered a priority over command hallucinations, which have a more immediate potential for harm.
Correct Answer is B
Explanation
A. "Why are you feeling so down?"
This response could come across as confrontational or invasive, potentially making the client feel uncomfortable. The client has already expressed their desire not to talk at the moment, so pushing for an explanation may not be well-received.
B. "I’ll just sit here with you for a few minutes then."
Explanation:
This response shows empathy and support without pushing the client to talk or sharing personal experiences. It respects the client's desire for space and acknowledges their emotions without being intrusive. It provides a calming and non-intrusive presence, giving the client the option to open up if and when they are ready.
C. "I understand. I've felt like that before, too."
While sharing personal experiences can sometimes be helpful, in this context, it might inadvertently shift the focus from the client's emotions to the nurse's experiences. It's important to keep the focus on the client and their feelings.
D. "It might help you feel better if you talk about it."
Suggesting that talking might help is well-intentioned, but it might pressure the client into discussing their feelings when they have clearly stated their preference not to at that moment. The client's autonomy and comfort should be respected.
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