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. "There really isn't much you can do about that until you are discharged." - This response dismisses the client's feelings and does not offer any support.

B. "You should call your boss and ask if you can have your job back." - This response is directive and may not address the client's emotional needs.

C. "You must feel very concerned and disappointed by that information."

This response shows empathy and acknowledges the client's feelings without making judgments or offering solutions. It validates the client's emotions and opens up a supportive space for further discussion.

D. "I don't understand why your partner would upset you with news like that." - This response may be perceived as judgmental and does not show empathy or understanding.

A. Speak to the provider about adding an MAOI to the current medication regimen. B. Explain that antidepressants often take several weeks to be fully effective. C. Tell the client that the provider will need to change citalopram to a different medication. D. Recommend a sleep study be done on the client

Correct Answer is B

Explanation

This action might be premature. MAOIs (Monoamine Oxidase Inhibitors) are a class of antidepressants with specific dietary and medication interactions. They are typically considered when other classes of antidepressants have not been effective. It's important to exhaust other options before considering a switch to MAOIs.

B. Explain that antidepressants often take several weeks to be fully effective:

Explanation: Correct Answer. This is an appropriate response. Antidepressants, including citalopram, can take several weeks to show their full therapeutic effects. It's common for some symptoms to improve before others. Educating the client about the delayed onset of action is important to manage their expectations.

C. Tell the client that the provider will need to change citalopram to a different medication:

Explanation: It might be too early to consider changing the medication after just two weeks, especially since the client reports an improved appetite. Changes in dosage or medication should ideally be discussed with the provider after an adequate trial period.

D. Recommend a sleep study be done on the client:

Explanation: While sleep problems can be associated with depression, it might not be the most appropriate next step based solely on the information provided. It's more important to address the ongoing depressive symptoms before focusing solely on sleep.

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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

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Correct Answer is C

Explanation

Correct Answer is B

Explanation

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