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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Related Questions
Correct Answer is B
Explanation
A. "Why are you feeling so down?"
This response could come across as confrontational or invasive, potentially making the client feel uncomfortable. The client has already expressed their desire not to talk at the moment, so pushing for an explanation may not be well-received.
B. "I’ll just sit here with you for a few minutes then."
Explanation:
This response shows empathy and support without pushing the client to talk or sharing personal experiences. It respects the client's desire for space and acknowledges their emotions without being intrusive. It provides a calming and non-intrusive presence, giving the client the option to open up if and when they are ready.
C. "I understand. I've felt like that before, too."
While sharing personal experiences can sometimes be helpful, in this context, it might inadvertently shift the focus from the client's emotions to the nurse's experiences. It's important to keep the focus on the client and their feelings.
D. "It might help you feel better if you talk about it."
Suggesting that talking might help is well-intentioned, but it might pressure the client into discussing their feelings when they have clearly stated their preference not to at that moment. The client's autonomy and comfort should be respected.
Correct Answer is C
Explanation
A. Antidepressants usually take several weeks to start taking effect, so the statement "I can be on my antidepressant taking three to five days to be effective" is not correct.
B. While positive thinking can play a role in managing mood, depression is a complex disorder that often requires more than just positive thoughts to treat. The statement "I can cure my depression by thinking positive thoughts" oversimplifies the condition.
C. "I will attend psychotherapy to help manage my depression."
Explanation:
Depressive disorders, including major depression, are complex conditions that typically require a multifaceted approach to treatment. Psychotherapy, also known as talk therapy, is an important component of treating depression. It involves working with a trained therapist to explore and address the thoughts, feelings, and behaviors contributing to the depression. Psychotherapy can help individuals develop coping strategies, improve problem-solving skills, and gain insight into their condition.
D. Depression is not something that can be simply chosen to be stopped voluntarily. It is a mental health disorder that often requires professional treatment and support. The statement "I need to make a voluntary choice to stop feeling depressed" does not accurately capture the nature of depression.
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