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

Answer and Explanation

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.

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Correct Answer is ["A","B","D","E"]

Explanation

A. Hyperactivity: While some individuals with eating disorders may engage in excessive physical activity as a form of compensatory behavior, hyperactivity is not a consistent and universal manifestation.

B. Amenorrhea: Adolescents with eating disorders, particularly anorexia nervosa, often experience amenorrhea (absence of menstrual periods) due to hormonal imbalances and low body weight.

C. Verbalized desire to gain weight: Individuals with eating disorders, especially anorexia nervosa, often express a strong desire to lose weight rather than gain weight, which contributes to their restrictive eating habits.

D. Altered body image: Eating disorders are often associated with distorted body image, where individuals perceive themselves as overweight or larger than they actually are, even if they are underweight.

E. Bradycardia: Severe malnutrition, as seen in eating disorders like anorexia nervosa, can lead to bradycardia (slow heart rate) as the body conserves energy in response to the low caloric intake.

A. "Are you thinking of harming yourself?" B. "Do you really think your family would be better off without you?" C. "When did you first start feeling this way?" D. "Tell me what is happening right now."

Correct Answer is A

Explanation

A. "Are you thinking of harming yourself?": Correct

This is the priority response because it directly addresses the client's statement about being better off gone, which raises concerns about potential suicidal thoughts. Asking this question allows the nurse to assess the client's risk of self-harm or suicide and take appropriate actions to ensure their safety.

B. "Do you really think your family would be better off without you?": Incorrect

While this response attempts to engage the client in a conversation, it doesn't directly address the immediate concern of suicidal thoughts. It's important to prioritize assessing the client's safety before exploring their feelings about their family's perspective.

C. "When did you first start feeling this way?": Incorrect

While understanding the client's history and the onset of their feelings is important, it's not the priority response in this situation. Assessing the client's risk of harm takes precedence over gathering historical information.

D. "Tell me what is happening right now.": Incorrect

This response doesn't directly address the client's statement about being better off gone and doesn't assess the immediate risk of self-harm or suicide. While understanding the client's current situation is valuable, safety concerns should be addressed first.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","D","E"]

Explanation

A client who has major depressive disorder states to the nurse that he and his family would be better off if he were gone. Which of the following is the nurse's priority response?

Correct Answer is A

Explanation

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