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. “Taking the medication on an empty stomach will decrease your stomach upset."This is incorrect because taking chlorpromazine on an empty stomach can actually increase the risk of gastrointestinal irritation and upset. It’s generally recommended to take medications that can irritate the stomach lining with food or milk to help buffer the stomach.

B. “Lie down for 30 minutes after each dose to help prevent stomach upset.”This is not a recommended practice for preventing stomach upset. In fact, lying down immediately after taking medication can increase the risk of esophageal irritation and reflux, especially with certain medications.

C. “Talk to your provider about decreasing your dose of medication.”While discussing medication concerns with a healthcare provider is always a good idea, this response does not directly address the immediate issue of stomach upset. The provider might adjust the dose if necessary, but the primary recommendation for reducing stomach upset would be to take the medication with milk.

D. “Drink a glass of milk with each dose of your medication.”Drinking milk with chlorpromazine can help reduce stomach upset by buffering the stomach lining and reducing irritation. This is a common recommendation for medications that can cause gastrointestinal discomfort.

A. Female gender B. Currently married C. Age greater than 45 years old D. Substance use disorder E. Schizophrenia: Correct

Correct Answer is ["C","D","E"]

Explanation

A. Female gender: Incorrect
While the risk of attempted suicide is generally higher in females, completed suicide rates are higher in males. Therefore, being female is not typically considered a primary risk factor for suicide,though it's important to note that both genders require attention for prevention.

B. Currently married: Incorrect
Being married is generally considered a protective factor against suicide. Social support and close relationships tend to reduce the risk of suicidal behavior.

C. Age greater than 45 years old: correct
Suicide risk tends to increase with age, particularly for men. Individuals over 45, especially those facing chronic illness, social isolation, or significant life changes, are at higher risk.

D. Substance use disorder: Correct
Substance use disorder is a significant risk factor for suicide. Substance abuse can contribute to feelings of hopelessness and despair, impair judgment, and lower inhibitions, increasing the likelihood of suicidal behavior.

E. Schizophrenia: Correct
Schizophrenia is a mental disorder associated with an increased risk of suicide. The symptoms of schizophrenia, such as hallucinations, delusions, and feelings of isolation, can contribute to severe distress and increase the risk of suicidal ideation and behaviors.

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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

A nurse is caring for a client who reports an upset stomach after taking chlorpromazine. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors for suicide? (Select all that apply).

Correct Answer is ["C","D","E"]

Explanation

A nurse is teaching a client who has a new prescription for chlorpromazine. Which of the following client statements indicates an understanding of the teaching?

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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?