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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) "I haven't gotten my period yet, and all my friends have theirs."
While the concern about not having gotten her period yet is a valid one, it's a common experience during adolescence. Variability in the timing of puberty is normal, and addressing this concern might involve providing reassurance and education about the natural range of development.
B) "There's a big pimple on my face, and I worry that everyone will notice it."
While concerns about physical appearance are common during adolescence, they are less urgent in terms of emotional and psychological well-being. Addressing body image issues is important, but the statement about lack of social acceptance and reciprocal liking indicates potentially deeper emotional challenges.
C) "None of the kids at this school like me, and I don't like them either."
Explanation:
Adolescence is a time of significant emotional and social development. The statement about not being liked by other students and not liking them in return indicates potential social isolation and difficulties in forming positive relationships. Adolescents often seek social acceptance and peer relationships are crucial for their well-being and development.
D) "My parents treat me like a baby sometimes."
This statement suggests a common parent-adolescent dynamic where there might be conflicts about independence and autonomy. While these feelings are valid, they don't necessarily reflect a higher priority concern related to social isolation and peer relationships.
Correct Answer is C
Explanation
While offering female assistive personnel for personal hygiene care is one option, it doesn't necessarily address the larger concern of the client's discomfort with a male nurse in her care team. The nurse manager's response should address the client's overall care and interactions.
B) "Your doctor is a man, so it seems like this should not be a problem."
Comparing the client's situation to the gender of the doctor might not be perceived as sensitive or supportive. The client's comfort with different members of the care team can vary, and it's important to address her concerns directly.
C) "I can review the assignments and arrange for a female nurse to care for you."
Explanation:
Respecting a patient's preferences and comfort is an important aspect of patient-centered care. If the female client expresses discomfort with a male nurse providing care due to her traumatic experience, it's appropriate for the nurse manager to accommodate her request if feasible. Changing the assignment to ensure that a female nurse provides care respects the client's wishes and helps create a more supportive and comfortable environment.
D) "The nurse assigned to care for you is very capable and cares for other women in this situation."
While it's important to emphasize the capabilities of the nurse, this response does not directly address the client's expressed discomfort with a male nurse. It's crucial to prioritize the client's feelings and concerns in this situation.
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