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 C

Explanation

A. A pretreatment electroencephalogram (EEG) will be done.

An EEG is not typically necessary when starting valproate for bipolar disorder. EEGs are more commonly used to assess brain activity in the context of epilepsy.

B. High serum sodium levels can cause toxic levels of valproate.

Sodium levels are not directly related to the toxic levels of valproate. The primary concern with valproate is its impact on liver function and potential for hepatotoxicity.

C. Liver function tests must be monitored.

Explanation: Valproate is an antiepileptic and mood-stabilizing medication commonly used to treat bipolar disorder. One of the potential side effects of valproate is hepatotoxicity (liver damage). Therefore, monitoring liver function tests (such as serum transaminases) is important to assess the medication's impact on the liver and to ensure the client's safety.

D. Thyroid function tests should be performed every 6 months.

While thyroid function tests might be important for some medications, monitoring thyroid function is not a primary consideration when using valproate. The main focus with valproate is on liver function monitoring.

A. Discuss self-defense techniques with the client. B. Give the client a bed bath prior to physical examination. C. Inform the client photographs of injuries are required for a police report. D. Ask the client to describe the situation.

Correct Answer is D

Explanation

A. Discuss self-defense techniques with the client: Incorrect

While self-defense techniques can be useful information, discussing them immediately after a traumatic event like sexual assault may not be appropriate. The client's immediate needs for emotional support, medical evaluation, and safety are more pressing.

B. Give the client a bed bath prior to physical examination: Incorrect

In cases of sexual assault, preserving evidence is important for legal purposes and for the client's well-being. Providing a bed bath could potentially compromise evidence and hinder a thorough examination by healthcare professionals.

C. Inform the client photographs of injuries are required for a police report: Correct

Preserving evidence is crucial in cases of sexual assault, especially if the client intends to involve law enforcement. Informing the client about the importance of photographs for a police report is appropriate and can contribute to a potential legal investigation.

D. Ask the client to describe the situation: Correct

It's important to encourage the client to share their experience, but it should be done in a sensitive and supportive manner. Gathering information about the situation can help the healthcare team understand the scope of the assault, provide appropriate medical care, and offer necessary emotional support.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client about the use of this medication?

Correct Answer is C

Explanation

A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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