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 D

Explanation

A. An adolescent client who throws objects at other clients:

Explanation: Seclusion is contraindicated for this client due to safety concerns. The behavior of throwing objects at others indicates a potential danger to both the client and others in a confined space. Placing the client in seclusion could escalate the situation and potentially lead to further harm.

B. An older adult client who is manic and crying due to overstimulation:

Explanation: Seclusion might be contraindicated for this client as well. Older adults experiencing manic behavior and emotional distress could be further traumatized by seclusion. Alternatives like providing a calm and soothing environment, along with appropriate medications, might be more beneficial for this client.

C. A school-age client who attempts to repeatedly bite staff:

Explanation: Seclusion is a potential option for this client. The repeated attempts to bite staff pose a risk of physical harm to both the client and staff members. Seclusion might be used as a last resort to ensure the safety of everyone involved.

D. An adult client following a suicide attempt:

Explanation: Seclusion is generally contraindicated for clients who have attempted suicide. Placing them in isolation can worsen feelings of despair and isolation, potentially increasing the risk of self-harm or suicide. These clients require close monitoring, support, and therapeutic interventions to address the underlying issues.

A. The client has begun playing basketball with several other clients during the past month. B. The client identifies with problems expressed by other clients. C. The client's behavior has become impulsive in the past few weeks. D. The client states she wants to go home to be with her children and partner.

Correct Answer is C

Explanation

A. The client has begun playing basketball with several other clients during the past month.

Engaging in activities and social interactions can actually be a positive sign, as it suggests involvement and connection with others, which can be protective against suicide.

B. The client identifies with problems expressed by other clients.

Identifying with others' problems may indicate empathy, but it is not necessarily indicative of suicide risk on its own.

C. The client's behavior has become impulsive in the past few weeks.

Explanation: Impulsivity can be a significant risk factor for suicide. A sudden increase in impulsive behavior might indicate that the client is not thinking clearly and is acting without considering the potential consequences. Impulsivity can lead to actions that are harmful or dangerous, including suicidal behaviors.

D. The client states she wants to go home to be with her children and partner.

Expressing a desire to be with loved ones is generally not an indicator of suicide risk. In fact, having a strong support system can be protective against suicidal thoughts.

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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

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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