A nurse on an inpatient mental health unit is assisting with the admission of a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following assessments should the nurse make first?

Suicide risk

Coping abilities

Psychiatric history

Support systems

Answer and Explanation

The Correct Answer is A

When assisting with the admission of a client who reports feeling depressed, sad, moody, and overly anxious, the nurse should prioritize assessing the client's suicide risk. This is because the client's symptoms, particularly feelings of depression and anxiety, can indicate a higher risk for self-harm or suicide. Assessing suicide risk is crucial to ensure the client's safety and provide appropriate interventions if needed.

incorrect:

B. Coping abilities: While assessing coping abilities is important to understand how the client manages stress and emotional challenges, it is secondary to assessing suicide risk. Coping abilities can be explored in subsequent assessments to determine the client's resilience and available resources for support.

C. Psychiatric history: Although understanding the client's psychiatric history is relevant for comprehensive care, it may not be the most immediate concern during the admission process. Assessing suicide risk takes precedence to ensure the client's safety.

D. Support systems: While assessing the client's support systems is valuable for understanding the available network of support, it should not take priority over assessing suicide risk. The client's immediate safety and potential need for intervention require immediate attention.

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Correct Answer is D

Explanation

Regression is a defense mechanism that involves reverting to an earlier stage of development or behaving in a way that is characteristic of an earlier developmental level in response to stress or anxiety. It is a way for individuals to cope with overwhelming emotions or situations by retreating to a previous, more comfortable state.

In the scenario described, the client's behavior of consistently being late for appointments and ignoring household chores while expressing the need to be taken care of indicates a regressive response to stress. By relying on others to take care of their responsibilities, the client is seeking a sense of security and support, similar to how they may have relied on others in the past, such as during childhood.

Inc

A- Repression involves the unconscious blocking of unacceptable thoughts or impulses from conscious awareness.

B- Introjection is the internalization of values or qualities of another person or group.

C- Dissociation is a defense mechanism that involves detaching oneself from reality or the present moment to avoid emotional distress.

A. Obtain client's weight weekly. B. Offer the client finger foods for meals. C. Speak loudly when addressing the client. D. Give long task at a time to the client E. Turn the clients TV on at night when they are unable to sleep. F. Encourage the client to take deep breaths when feeling agitated. G. Assess client's memory every shift.

Correct Answer is ["A","B","F","G"]

Explanation

From the given information, the nurse should include the following interventions in the plan of care for the client with dementia:
● Obtain client's weight weekly: Regular weight monitoring helps assess the client's nutritional status and detect any significant changes that may require intervention.
● Offer the client finger foods for meals: Finger foods can be easier for the client to handle and consume independently, promoting independence and self-feeding.
● Encourage the client to take deep breaths when feeling agitated: Deep breathing exercises can help the client manage their agitation and promote relaxation.
● Assess client's memory every shift: Regular assessment of the client's memory allows for monitoring any changes or decline, which helps in planning appropriate interventions and providing necessary support.
The following interventions should be avoided:

● Speak loudly when addressing the client: Speaking loudly may cause confusion or agitation in the client. Instead, it is recommended to use a calm and reassuring tone of voice.
● Give long tasks at a time to the client: Clients with dementia often have difficulty with concentration and memory. Providing long tasks may overwhelm them and contribute to their frustration. Breaking tasks into smaller, manageable steps is more appropriate.

● Turn the client's TV on at night when they are unable to sleep: It is generally recommended to create a quiet and calming environment for sleep. The TV may interfere with the client's sleep and contribute to increased agitation or confusion.

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A nurse on an inpatient mental health unit is assisting with the admission of a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following assessments should the nurse make first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse working in a long-term care facility is admitting a client who has dementia. Exhibits Which of the following interventions should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["A","B","F","G"]

Explanation

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