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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer: C
Rationale:
A) Displacement:
Displacement involves redirecting emotions or feelings from the original source to a safer or more acceptable substitute. In this scenario, the client is not redirecting their feelings about their condition onto another person or object, so displacement does not apply.
B) Reaction formation:
Reaction formation is when a person behaves in a way that is opposite to their actual feelings or thoughts to conceal them. The client is not expressing the opposite of their true feelings about their condition; instead, they are downplaying the seriousness of their diagnosis.
C) Denial:
Denial involves refusing to accept reality or facts, thus blocking external events from awareness. By believing that proper diet and exercise alone will make the joint pain go away, the client is refusing to accept the chronic nature of their condition and its long-term implications.
D) Rationalization:
Rationalization involves creating logical reasons or excuses for behaviors or feelings to avoid facing the true reasons. The client is not making excuses or trying to justify their feelings; instead, they are denying the chronic nature of their arthritis, which makes denial the correct defense mechanism in this context.
Correct Answer is D
Explanation
Cognitive reframing involves changing negative or unhelpful thought patterns into more positive and constructive ones. By learning to change negative thoughts into positive statements, the client is actively engaging in cognitive reframing. This process helps the client challenge and reframe negative thoughts, replacing them with more positive and adaptive thoughts. By doing so, the client can reduce stress, improve their mood, and approach challenging situations with a more positive mindset. This technique is an effective way to cope with stress and promote emotional well-being.
Incorrect:
A. The client trains his mind to relax by using deep inner resources. This choice refers to relaxation techniques, which can be helpful for stress reduction but are not specifically related to cognitive reframing. Cognitive reframing focuses on changing thought patterns rather than relaxation techniques.
B. The client learns the source of his stress by writing down daily events. While identifying the source of stress can be an important step in stress management, it is not specific to cognitive reframing. Cognitive reframing involves challenging and changing negative thoughts, rather than solely focusing on identifying stressors.
C. The client imagines being in a quiet, relaxing environment. This choice refers to visualization or guided imagery techniques, which can also be helpful for relaxation but are not specifically related to cognitive reframing. Cognitive reframing involves changing thoughts, beliefs, and interpretations, rather than focusing on imagining specific environments.
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