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 A
Explanation
Establishing a consistent bedtime routine and sleep schedule can promote better sleep hygiene and help regulate the client's sleep-wake cycle. By getting the client ready for sleep at the same time each night, the nurse helps create a predictable and calming routine that signals to the body that it is time to sleep.
Incorrect:
B. Move the client to a room next to the open nurses' station: This measure may increase noise and disturbances, which can further disrupt the client's sleep. Providing a quiet and peaceful environment is generally more conducive to restful sleep.
C. Encourage the client to take a 1-hour nap each afternoon: While short daytime naps can be beneficial for some individuals, they may interfere with the client's ability to fall asleep or stay asleep at night. It is generally recommended to limit daytime napping, especially if the client is having trouble sleeping at night.
D. Play the client's favorite music in the room while the client is sleeping: While some individuals find soothing music helpful for relaxation and sleep, it is essential to consider the client's preferences. Not everyone finds music helpful for sleep, and it is important to respect the client's preferences and individual needs. Some clients may find silence or white noise more conducive to sleep.
Correct Answer is C
Explanation
Repression is a defense mechanism that involves pushing distressing or anxiety-provoking thoughts, memories, or impulses into the unconscious mind. By repressing these thoughts, the individual can avoid dealing with the associated anxiety or discomfort. In the given scenario, the client escapes from anxiety-causing thoughts by ignoring their existence, which aligns with the concept of repression.
Denial, another defense mechanism, involves refusing to acknowledge the existence of a distressing reality or truth. However, in this case, the client is not denying the existence of the thoughts but rather ignoring or avoiding them.
Splitting is a defense mechanism characterized by the inability to integrate positive and negative qualities of oneself or others into a cohesive whole. It is not applicable in this situation.
Sublimation is a defense mechanism in which individuals redirect their unacceptable impulses into more socially acceptable outlets. It involves channeling potentially harmful or unacceptable desires into constructive behaviors. The given scenario does not reflect sublimation as the individual is not redirecting their anxiety into a productive activity or behavior.
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