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 A

Explanation

The appropriate response for the nurse in this situation is to acknowledge the partner's concern and empathize with their feelings. By stating, "It must be very difficult for you to see your wife in pain," the nurse acknowledges the partner's emotions and shows understanding and empathy. This response validates the partner's feelings and demonstrates support and compassion.

B- "We're doing everything we can to keep your wife comfortable" may be a true statement, but it does not directly address the partner's expressed wish to do something to help. It may not fully address the emotional aspect of the partner's statement.

C- "I wish there was more that I could do to relieve your wife's pain, too" is a genuine response that expresses empathy. It acknowledges the partner's desire to help and implies that the nurse shares the same sentiment. This response shows understanding and support.

D- "I'm sure your wife will begin to feel better soon" dismisses the partner's concern and does not address their expressed wish to alleviate their wife's pain. It may not fully acknowledge the partner's emotions or provide the support they need in that moment.

A. "You really should work hard to stay on the schedule we establish here." B. "I wouldn't worry about what you've done in the past. You'll do just fine this time." C. "Why do you find it difficult to take your medications if they improve your condition?" D. "Let's work together to devise a schedule that is convenient for you on a daily basis."

Correct Answer is D

Explanation

The response "Let's work together to devise a schedule that is convenient for you on a daily basis" demonstrates a collaborative and patient-centered approach. It acknowledges the client's difficulty in following a medication regimen and suggests finding a solution that works for the client's lifestyle and needs. By involving the client in the process and considering their preferences and challenges, the nurse can increase the chances of medication adherence.

The response "You really should work hard to stay on the schedule we establish here" may come across as judgmental and may not address the underlying reasons for the client's difficulty in medication adherence. It does not promote a collaborative and supportive environment.

The response "I wouldn't worry about what you've done in the past. You'll do just fine this time" dismisses the client's concerns and does not provide practical strategies to improve medication adherence. It does not address the client's specific challenge or offer any support.

The response "Why do you find it difficult to take your medications if they improve your condition?" is a probing question that seeks to understand the client's reasons for struggling with medication adherence. While it may be important to explore the underlying reasons, it should be followed by a supportive and collaborative approach to finding solutions.

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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

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