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 C
Explanation
A. Bleeding:
Explanation: Bleeding is not a common adverse effect of haloperidol, which is an antipsychotic medication used to treat conditions like schizophrenia. Haloperidol primarily works on the central nervous system and is not known to directly cause bleeding issues.
B. Cataracts:
Explanation: Cataracts are not a common adverse effect of haloperidol either. While long-term use of some antipsychotic medications can lead to metabolic and endocrine disturbances, which might indirectly impact eye health, cataracts are not a direct and immediate concern with haloperidol use.
C. Dysrhythmias:
Explanation: Correct Answer. Haloperidol has the potential to cause cardiac-related adverse effects, including dysrhythmias (irregular heart rhythms). This is a particular concern in individuals who are predisposed to heart conditions or have other risk factors. The medication can prolong the QT interval, which is a measure of the time it takes for the heart's electrical system to recharge between beats. Prolonged QT interval can lead to serious and potentially life-threatening arrhythmias.
D. Pancreatitis:
Explanation: Pancreatitis is not a common adverse effect of haloperidol. Pancreatitis typically involves inflammation of the pancreas and can be caused by various factors such as gallstones, alcohol consumption, and certain medications. Haloperidol is not known to directly cause inflammation of the pancreas.
Correct Answer is D
Explanation
A. “Taking the medication on an empty stomach will decrease your stomach upset."This is incorrect because taking chlorpromazine on an empty stomach can actually increase the risk of gastrointestinal irritation and upset. It’s generally recommended to take medications that can irritate the stomach lining with food or milk to help buffer the stomach.
B. “Lie down for 30 minutes after each dose to help prevent stomach upset.”This is not a recommended practice for preventing stomach upset. In fact, lying down immediately after taking medication can increase the risk of esophageal irritation and reflux, especially with certain medications.
C. “Talk to your provider about decreasing your dose of medication.”While discussing medication concerns with a healthcare provider is always a good idea, this response does not directly address the immediate issue of stomach upset. The provider might adjust the dose if necessary, but the primary recommendation for reducing stomach upset would be to take the medication with milk.
D. “Drink a glass of milk with each dose of your medication.”Drinking milk with chlorpromazine can help reduce stomach upset by buffering the stomach lining and reducing irritation. This is a common recommendation for medications that can cause gastrointestinal discomfort.
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