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?

A. Determining if the client has psychotic thinking.

Explanation: 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.

A) "My child was born with a birth defect due to an exposure I had overseas."

This statement does not directly relate to the core symptoms of PTSD. While exposure to trauma can have a variety of consequences, including potential exposure-related health issues, this statement does not necessarily indicate the re-experiencing, avoidance, or hyperarousal symptoms characteristic of PTSD.

B) "I check any room I enter because the enemy is still after me and could be hiding anywhere."

This statement is more indicative of hyperarousal and hypervigilance, which are common symptoms of PTSD. However, it does not explicitly involve re-experiencing the traumatic event through nightmares or intrusive memories, as described in the correct answer.

C) "In my dreams, all I can see are the wounded reaching out and trying to grab me."

Explanation:

The statement "In my dreams, all I can see are the wounded reaching out and trying to grab me" indicates symptoms commonly associated with posttraumatic stress disorder (PTSD). This statement reflects the re-experiencing symptom cluster of PTSD, where individuals may have distressing and intrusive memories, nightmares, or flashbacks related to the traumatic event they experienced. The imagery of wounded individuals trying to grab the person suggests a strong emotional impact and ongoing distress related to the traumatic experience.

D) "I killed four enemy soldiers with my bare hands and saved my entire battalion."

While this statement might reflect exposure to a traumatic event and could contribute to symptoms of PTSD, it is presented in a way that seems more like a narrative of heroic actions rather than a symptom of distress or re-experiencing.