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
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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Related Questions
Correct Answer is D
Explanation
The response "You are feeling drawn in two different directions" acknowledges the daughter's conflicting feelings and validates her emotions. It demonstrates empathy and understanding of her situation. It can help the daughter feel heard and supported and opens up an opportunity for further conversation about her concerns and possible solutions.
The other options are less appropriate:
A- "Don't worry. We'll take good care of your father while you are gone." While this response reassures the daughter about her father's care, it does not address her emotional conflict or provide support for her own needs and concerns.
B- "Perhaps you could stay here and just call your family to see how they are doing." This response minimizes the daughter's situation and does not fully acknowledge her need to be with her own family. It may overlook the emotional strain and responsibilities she may have outside of the hospital.
C-"There's nothing you can do here. You should go home to your family." This response dismisses the daughter's feelings and implies that her presence is not necessary or valuable. It does not consider her desire to support her father or the importance of maintaining a connection with him during his hospitalization.
Correct Answer is D
Explanation
Autonomy is the ethical principle that upholds an individual's right to make decisions about their own care and treatment. Respecting autonomy means acknowledging and honoring a person's right to make choices based on their own values, beliefs, and preferences. By importing a client's wishes to refuse prescribed treatments, the nurse is recognizing and respecting the client's autonomy. This shows that the nurse values the client's right to make decisions about their own healthcare and supports their choice, even if it may differ from what the nurse may recommend.
Incorrect:
A. Spending extra time to calm an agitated client demonstrates the ethical principle of beneficence, which is the duty to promote the well-being and welfare of the client.
B. Ensuring that a client understands expectations for group participation relates to the ethical principle of fidelity, which involves maintaining trust and keeping promises to the client.
C. Describing the adverse effects of a client's medications is important for informed consent and promoting understanding, but it does not directly involve the client's autonomy unless it is accompanied by a discussion of the client's choices and preferences regarding medication.
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